Provider Demographics
NPI:1285893347
Name:RANDALL BOCK MD PC
Entity type:Organization
Organization Name:RANDALL BOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOCK
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:617-982-2865
Mailing Address - Street 1:1660 SOLDIERS FIELD RD # 1021
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1108
Mailing Address - Country:US
Mailing Address - Phone:617-982-2865
Mailing Address - Fax:
Practice Address - Street 1:1660 SOLDIERS FIELD RD # 1021
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-1108
Practice Address - Country:US
Practice Address - Phone:617-901-4847
Practice Address - Fax:781-286-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA51810208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04222OtherBLUE CROSS BLUE SHIELD
MA6199682Medicaid
MAJ04222OtherBLUE CROSS BLUE SHIELD