Basic Information
| Provider Information | |||||||||
| NPI: | 1013227768 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UMASS MEMORIAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
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| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 BOYDEN RD | ||||||||
| Address2: | |||||||||
| City: | HOLDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015202542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088299944 | ||||||||
| FaxNumber: | 5088292100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 10/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | STREETER | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5083340311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 24170 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.