Provider Demographics
NPI:1336976539
Name:REVERE MEDICAL OF MASSACHUSETTS, PC
Entity type:Organization
Organization Name:REVERE MEDICAL OF MASSACHUSETTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-672-7122
Mailing Address - Street 1:40 BURTON HILLS BLVD STE 370
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6287
Mailing Address - Country:US
Mailing Address - Phone:615-672-7122
Mailing Address - Fax:615-672-7849
Practice Address - Street 1:1 PEARL ST STE 2200
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2874
Practice Address - Country:US
Practice Address - Phone:615-672-7122
Practice Address - Fax:615-672-7849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty