Provider Demographics
NPI:1295873784
Name:SOUTHWEST BOSTON INTERNAL MEDICINE ASSOCIATES, PC
Entity type:Organization
Organization Name:SOUTHWEST BOSTON INTERNAL MEDICINE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BEAUREGARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:781-326-7815
Mailing Address - Street 1:200 PROVIDENCE HWY
Mailing Address - Street 2:SUITE 202-203
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1881
Mailing Address - Country:US
Mailing Address - Phone:781-326-7815
Mailing Address - Fax:
Practice Address - Street 1:200 PROVIDENCE HWY
Practice Address - Street 2:SUITE 202-203
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1881
Practice Address - Country:US
Practice Address - Phone:781-326-7815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17512OtherBCBS
MA3065260Medicaid
MAM21138Medicare PIN