Basic Information
| Provider Information | |||||||||
| NPI: | 1679131361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UMASS MEMORIAL MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415353 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083341840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016550002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083341000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2019 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | AMAYA | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5083346503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1005X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal | 133VN1006X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.