Provider Demographics
NPI:1962451591
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PUNYAMURTULA
Authorized Official - Middle Name:
Authorized Official - Last Name:KISHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-383-6567
Mailing Address - Street 1:11 KENT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7901
Mailing Address - Country:US
Mailing Address - Phone:617-383-6405
Mailing Address - Fax:
Practice Address - Street 1:11 KENT ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7901
Practice Address - Country:US
Practice Address - Phone:617-383-6405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9772898Medicaid
M15800Medicare PIN