Basic Information
| Provider Information | |||||||||
| NPI: | 1538373295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARVARD VANGUARD MEDICAL ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 GROVE STREET | ||||||||
| Address2: | SUITE 3-300 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 ESSEX CENTER DR | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019602902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785322800 | ||||||||
| FaxNumber: | 9789774226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | BURNES | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175598393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 164W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0029501 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | M18223 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |