Healthcare Provider Details

I. General information

NPI: 1861448797
Provider Name (Legal Business Name): MASSACHUSETTS MOBILE PET PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LINCOLN AVE
HAVERHILL MA
01830-6700
US

IV. Provider business mailing address

35 NEW ENGLAND BUSINESS CENTER DR STE 103
ANDOVER MA
01810-1080
US

V. Phone/Fax

Practice location:
  • Phone: 978-689-4738
  • Fax: 978-682-0984
Mailing address:
  • Phone: 978-933-9302
  • Fax: 978-933-7820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number44-0373
License Number StateMA

VIII. Authorized Official

Name: MARK R TAYLOR
Title or Position: CEO
Credential:
Phone: 978-933-9311