Basic Information
| Provider Information | |||||||||
| NPI: | 1578528949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC CLINICAL ASSOC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177546742 | ||||||||
| FaxNumber: | 6177546443 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177546742 | ||||||||
| FaxNumber: | 6177546443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | BIERBAUM | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6177546742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9731393 | 05 | MA | MEDICAID |