Healthcare Provider Details

I. General information

NPI: 1609872886
Provider Name (Legal Business Name): PENTUCKET MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE PARKWAY
HAVERHILL MA
01830
US

IV. Provider business mailing address

ONE PARKWAY
HAVERHILL MA
01830
US

V. Phone/Fax

Practice location:
  • Phone: 978-521-3200
  • Fax: 978-469-5363
Mailing address:
  • Phone: 978-521-3200
  • Fax: 978-374-9792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0018028
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerNEIGHBORHOOD HEALTH PLAN
# 2
Identifier681017
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS
# 3
Identifier9786376
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 4
Identifier5313652
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 5
IdentifierM17320
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS
# 6
Identifier30210443
Identifier TypeOTHER
Identifier StateNH
Identifier IssuerNH MEDICAID

VIII. Authorized Official

Name: DR. THOMAS LOUIS FAZIO
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 978-557-8920