Provider Demographics
NPI:1205992989
Name:AMBAMA CLINIC PC
Entity type:Organization
Organization Name:AMBAMA CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-296-0720
Mailing Address - Street 1:56 COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-6347
Mailing Address - Country:US
Mailing Address - Phone:617-296-0720
Mailing Address - Fax:617-296-5166
Practice Address - Street 1:56 COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-6347
Practice Address - Country:US
Practice Address - Phone:617-296-0720
Practice Address - Fax:617-296-5166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52194207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9728350Medicaid
MA0030542OtherNEIGHBORHOOD HEALTH PLAN
MAM18330OtherBLUE CROSS BLUE SHIELD MA
MADA4008OtherRAILROAD MEDICARE GROUP
MA697380OtherTUFTS HEALTH PLAN
MAF80450Medicare UPIN
MAM21353Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER