Healthcare Provider Details

I. General information

NPI: 1922367168
Provider Name (Legal Business Name): LONGWOOD ACADEMIC PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 GROTON RD SUITE 2
AYER MA
01432-1177
US

IV. Provider business mailing address

198 GROTON RD SUITE 2
AYER MA
01432-1177
US

V. Phone/Fax

Practice location:
  • Phone: 978-772-3793
  • Fax: 978-772-3797
Mailing address:
  • Phone: 978-772-3793
  • Fax: 978-772-3797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number76993
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number76993
License Number StateMA

VIII. Authorized Official

Name: JOHN DIGIORGIO
Title or Position: DIRECTOR OF NETWORK OPERATIONS
Credential:
Phone: 617-632-7373