Healthcare Provider Details

I. General information

NPI: 1407860968
Provider Name (Legal Business Name): DEDHAM MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE LYONS ST
DEDHAM MA
02026
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 Code208800000X
TaxonomyUrology Physician
License Number
License Number StateMA

VIII. Authorized Official

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