Provider Demographics
NPI:1023142668
Name:THOMAS J. SCORNAVACCA, JR.
Entity type:Organization
Organization Name:THOMAS J. SCORNAVACCA, JR.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER. PHYSICIAN.
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCORNAVACCA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:978-534-8607
Mailing Address - Street 1:50 MEMORIAL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2238
Mailing Address - Country:US
Mailing Address - Phone:978-534-8607
Mailing Address - Fax:978-840-4670
Practice Address - Street 1:50 MEMORIAL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2238
Practice Address - Country:US
Practice Address - Phone:978-534-8607
Practice Address - Fax:978-840-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
155208OtherTUFTS
M17805OtherBLUE SHIELD
MAG73795Medicare UPIN