Provider Demographics
NPI:1255162566
Name:INTERWELL HEALTH MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:INTERWELL HEALTH MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:833-644-8244
Mailing Address - Street 1:68 HARRISON AVE STE 605 PMB 39516
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:833-664-8244
Mailing Address - Fax:
Practice Address - Street 1:461 CALLE FRANCIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-4204
Practice Address - Country:US
Practice Address - Phone:833-664-8244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty