Provider Demographics
NPI:1063527299
Name:ORTHOPEDIC SURGERY OF QUINCY INC
Entity type:Organization
Organization Name:ORTHOPEDIC SURGERY OF QUINCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICECCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-773-7457
Mailing Address - Street 1:300 CONGRESS STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-7457
Mailing Address - Fax:617-773-0299
Practice Address - Street 1:300 CONGRESS STREET
Practice Address - Street 2:SUITE 308
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-7457
Practice Address - Fax:617-773-0299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA705664OtherTUFTS
MA9707808Medicaid
MAM11024OtherMA BCBS
M11024Medicare ID - Type Unspecified