Healthcare Provider Details

I. General information

NPI: 1003242751
Provider Name (Legal Business Name): TAK MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 OLD ROAD TO 9 ACRE COR
CONCORD MA
01742-4159
US

IV. Provider business mailing address

48 NELSON STREET
LEOMINSTER MA
01453-1234
US

V. Phone/Fax

Practice location:
  • Phone: 978-466-4396
  • Fax: 978-466-4029
Mailing address:
  • Phone: 978-466-4396
  • Fax: 978-466-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND D. FREDETTE
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 978-466-4033