Healthcare Provider Details

I. General information

NPI: 1740280817
Provider Name (Legal Business Name): DEDHAM MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LYONS ST
DEDHAM MA
02026-5599
US

IV. Provider business mailing address

PO BOX 9120
DEDHAM MA
02027-9120
US

V. Phone/Fax

Practice location:
  • Phone: 781-329-1400
  • Fax: 781-278-5667
Mailing address:
  • Phone: 781-329-1400
  • Fax: 781-278-5667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9766529
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier9766588
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 3
Identifier9766561
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 4
Identifier9766537
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 5
Identifier9766618
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 6
Identifier9766596
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 7
Identifier9766634
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 8
Identifier9766545
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 9
Identifier9766553
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 10
Identifier9766626
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MR. RICHARD M RUSSO
Title or Position: CFO
Credential:
Phone: 781-278-5540