Provider Demographics
NPI:1750528352
Name:CENTRAL SQUARE MEDICAL CENTER INC
Entity type:Organization
Organization Name:CENTRAL SQUARE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR /OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:GORBATOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-366-3844
Mailing Address - Street 1:40 CENTRAL SQ
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1911
Mailing Address - Country:US
Mailing Address - Phone:617-202-9036
Mailing Address - Fax:
Practice Address - Street 1:40 CENTRAL SQ
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1911
Practice Address - Country:US
Practice Address - Phone:617-202-9036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center