Provider Demographics
NPI:1487163069
Name:MASS GENERAL BRIGHAM COMMUNITY PHYSICIANS ON DEMAND
Entity type:Organization
Organization Name:MASS GENERAL BRIGHAM COMMUNITY PHYSICIANS ON DEMAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-282-2028
Mailing Address - Street 1:399 REVOLUTION DR STE 1010
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1473
Mailing Address - Country:US
Mailing Address - Phone:857-282-2028
Mailing Address - Fax:857-282-5912
Practice Address - Street 1:370 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1788
Practice Address - Country:US
Practice Address - Phone:978-557-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
MA229944261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty