Provider Demographics
NPI:1962774638
Name:MIDDLESEX RECOVERY PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MIDDLESEX RECOVERY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-605-0944
Mailing Address - Street 1:405 PEARL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6644
Mailing Address - Country:US
Mailing Address - Phone:781-605-0944
Mailing Address - Fax:781-605-3710
Practice Address - Street 1:405 PEARL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6644
Practice Address - Country:US
Practice Address - Phone:781-605-0944
Practice Address - Fax:781-605-3710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72453207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty