Provider Demographics
NPI:1356515464
Name:SQUARE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SQUARE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:LEONID
Authorized Official - Last Name:LENDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-916-5069
Mailing Address - Street 1:124 WATERTOWN ST
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2576
Mailing Address - Country:US
Mailing Address - Phone:617-916-5069
Mailing Address - Fax:617-467-4073
Practice Address - Street 1:124 WATERTOWN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2576
Practice Address - Country:US
Practice Address - Phone:617-916-5069
Practice Address - Fax:617-467-4073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152859261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3173615Medicaid
MA3173615Medicaid