Provider Demographics
| NPI: | 1770563900 |
|---|---|
| Name: | HALLMARK HEALTH MEDICAL ASSOCIATES INC |
| Entity type: | Organization |
| Organization Name: | HALLMARK HEALTH MEDICAL ASSOCIATES INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VICE PRESIDENT FISCAL SERVICES |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | S |
| Authorized Official - Last Name: | TURILLI |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 781-338-7415 |
| Mailing Address - Street 1: | PO BOX 3237 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WOBURN |
| Mailing Address - State: | MA |
| Mailing Address - Zip Code: | 01888-3237 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 781-338-7170 |
| Mailing Address - Fax: | 781-338-7173 |
| Practice Address - Street 1: | 170 GOVERNORS AVE |
| Practice Address - Street 2: | ATTN: PROVIDER ENROLLMENT |
| Practice Address - City: | MEDFORD |
| Practice Address - State: | MA |
| Practice Address - Zip Code: | 02155-1643 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 781-338-7521 |
| Practice Address - Fax: | 781-338-7531 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | HALLMARK HEALTH COPORATION |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-01-23 |
| Last Update Date: | 2009-11-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LX0001X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | Group - Multi-Specialty |
| No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MA | M15828 | Other | BLUE CROSS GROUP PROV # |
| MA | 9771336 | Medicaid | |
| MA | M15828 | Medicare PIN |
