Provider Demographics
NPI:1770142945
Name:COMMONWEALTH MEDICINE
Entity type:Organization
Organization Name:COMMONWEALTH MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAVENTURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-886-8013
Mailing Address - Street 1:529 MAIN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1125
Mailing Address - Country:US
Mailing Address - Phone:617-886-8264
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:617-886-8264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local