Provider Demographics
NPI:1881059665
Name:OPTIMAL PROFESSIONAL HEALTH SERVICES PC
Entity type:Organization
Organization Name:OPTIMAL PROFESSIONAL HEALTH SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-364-1440
Mailing Address - Street 1:944 WASHINGTON ST
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1177
Mailing Address - Country:US
Mailing Address - Phone:508-238-8646
Mailing Address - Fax:508-230-9772
Practice Address - Street 1:1418 PROVIDENCE HWY
Practice Address - Street 2:SUITE N
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4655
Practice Address - Country:US
Practice Address - Phone:617-964-1440
Practice Address - Fax:617-964-7833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110109264AMedicaid
MAS100283834Medicare PIN