Healthcare Provider Details

I. General information

NPI: 1821362294
Provider Name (Legal Business Name): WOODBINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 INDUSTRIAL DR SUITE 100
MASHPEE MA
02649-3464
US

IV. Provider business mailing address

5 INDUSTRIAL DR SUITE 100
MASHPEE MA
02649-3464
US

V. Phone/Fax

Practice location:
  • Phone: 508-477-4282
  • Fax: 508-539-6134
Mailing address:
  • Phone: 508-477-4282
  • Fax: 508-539-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number51965
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TEDI C MARSH
Title or Position: BUSINESS MANAGER
Credential: CPC, CPP-P
Phone: 508-539-6188