Provider Demographics
NPI:1215744057
Name:MASS GENERAL BRIGHAM
Entity type:Organization
Organization Name:MASS GENERAL BRIGHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER, SPORTS MEDICINE
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-219-1280
Mailing Address - Street 1:168 W 9TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-7720
Mailing Address - Country:US
Mailing Address - Phone:339-225-0541
Mailing Address - Fax:
Practice Address - Street 1:978 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-3709
Practice Address - Country:US
Practice Address - Phone:617-219-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEWTON WELLESLEY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty