Provider Demographics
NPI:1265421424
Name:QMC ED PHYSICIANS
Entity type:Organization
Organization Name:QMC ED PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVAIO-BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-376-4018
Mailing Address - Street 1:2600 HORIZON DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 WHITWELL ST
Practice Address - Street 2:ATTN EMERGENCY DEPT
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1870
Practice Address - Country:US
Practice Address - Phone:617-376-5549
Practice Address - Fax:617-376-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
56804207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19402OtherBCBS
MA9772871Medicaid
MAM19402OtherBCBS
MA0002347Medicare PIN