Healthcare Provider Details

I. General information

NPI: 1285340323
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF MEDFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST STE 201
MEDFORD MA
02155-4530
US

IV. Provider business mailing address

101 MAIN ST STE 201
MEDFORD MA
02155-4530
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-1288
  • Fax: 781-391-1989
Mailing address:
  • Phone: 781-396-1288
  • Fax: 781-391-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ROB BURNETT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 781-396-9024