Provider Demographics
NPI:1063716579
Name:MGH
Entity type:Organization
Organization Name:MGH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-889-8580
Mailing Address - Street 1:10 TALL TREE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-979-7410
Mailing Address - Fax:
Practice Address - Street 1:10 TALL TREE DR
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2012
Practice Address - Country:US
Practice Address - Phone:978-979-7410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MG17508
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179866281P00000X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No281P00000XHospitalsChronic Disease Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1003910548OtherNPI