Healthcare Provider Details

I. General information

NPI: 1205215373
Provider Name (Legal Business Name): MASS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTRAL ST SUITE #2
LOWELL MA
01852-2201
US

IV. Provider business mailing address

200 CENTRAL ST UNIT 2
LOWELL MA
01852-2201
US

V. Phone/Fax

Practice location:
  • Phone: 978-446-7982
  • Fax: 866-897-3951
Mailing address:
  • Phone: 978-446-7982
  • Fax: 866-897-3951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number223435
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number223435
License Number StateMA

VIII. Authorized Official

Name: HAMID REZA DANESH
Title or Position: MEMBER
Credential: MD
Phone: 978-888-3147