Healthcare Provider Details

I. General information

NPI: 1700191889
Provider Name (Legal Business Name): COOLIDGE CORNER IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 HARVARD ST
BROOKLINE MA
02446-2905
US

IV. Provider business mailing address

356 HARVARD ST
BROOKLINE MA
02446-2905
US

V. Phone/Fax

Practice location:
  • Phone: 617-383-6585
  • Fax: 617-383-6592
Mailing address:
  • Phone: 617-383-6585
  • Fax: 617-383-6592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD B MARIANACCI
Title or Position: MANAGER
Credential: M.D.
Phone: 617-383-6585