Provider Demographics
NPI:1356399562
Name:RESERVOIR MEDICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:RESERVOIR MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-661-4600
Mailing Address - Street 1:725 CONCORD AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1040
Mailing Address - Country:US
Mailing Address - Phone:617-661-4600
Mailing Address - Fax:617-547-9170
Practice Address - Street 1:725 CONCORD AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1040
Practice Address - Country:US
Practice Address - Phone:617-661-4600
Practice Address - Fax:617-547-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57930207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9776036Medicaid
MA609088OtherTUFTS
MAM16171OtherBCBS
MA609088OtherTUFTS