Provider Demographics
NPI:1528353612
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:154 LYNNWAY
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3479
Mailing Address - Country:US
Mailing Address - Phone:781-584-6106
Mailing Address - Fax:
Practice Address - Street 1:154 LYNNWAY
Practice Address - Street 2:SUITE 1C
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3479
Practice Address - Country:US
Practice Address - Phone:781-584-6106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVE MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty