Healthcare Provider Details

I. General information

NPI: 1568760601
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2011
Last Update Date: 03/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501B WASHINGTON ST
DORCHESTER CENTER MA
02124-2014
US

IV. Provider business mailing address

501B WASHINGTON ST
DORCHESTER CENTER MA
02124-2014
US

V. Phone/Fax

Practice location:
  • Phone: 617-506-0160
  • Fax: 617-506-0777
Mailing address:
  • Phone: 617-506-0160
  • Fax: 617-506-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY J DELONG
Title or Position: CREDENTIALING MANAGER
Credential: MM, RHIA
Phone: 413-222-7711