Provider Demographics
NPI:1073660015
Name:RAD RHEUMATOLOGY & AUTOIMMUNE DISORDERS LLC
Entity type:Organization
Organization Name:RAD RHEUMATOLOGY & AUTOIMMUNE DISORDERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:FEOKTISTOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-822-2874
Mailing Address - Street 1:851 MAIN ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1612
Mailing Address - Country:US
Mailing Address - Phone:508-822-2874
Mailing Address - Fax:508-880-0450
Practice Address - Street 1:851 MAIN ST
Practice Address - Street 2:SUITE 14
Practice Address - City:S WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1612
Practice Address - Country:US
Practice Address - Phone:508-822-2874
Practice Address - Fax:508-880-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211533207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9781510Medicaid
MA9781510Medicaid
MAM21727Medicare PIN
M21728Medicare PIN