Provider Demographics
NPI:1699920850
Name:ROBERT DETERS, MD, INTERVENTIONAL PAIN MANAGEMENT
Entity type:Organization
Organization Name:ROBERT DETERS, MD, INTERVENTIONAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FABELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-466-4243
Mailing Address - Street 1:50 MEMORIAL DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2238
Mailing Address - Country:US
Mailing Address - Phone:978-466-2121
Mailing Address - Fax:978-466-2274
Practice Address - Street 1:50 MEMORIAL DR
Practice Address - Street 2:SUITE 207
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2238
Practice Address - Country:US
Practice Address - Phone:978-466-2121
Practice Address - Fax:978-466-2274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COORDINATED PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9771476Medicaid
MAM20928Medicare PIN