Healthcare Provider Details

I. General information

NPI: 1255964391
Provider Name (Legal Business Name): HALLMARK HEALTH MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GOVERNORS AVE
MEDFORD MA
02155-1643
US

IV. Provider business mailing address

PO BOX 3237
WOBURN MA
01888-3237
US

V. Phone/Fax

Practice location:
  • Phone: 781-338-7170
  • Fax: 781-338-7173
Mailing address:
  • Phone: 781-338-7170
  • Fax: 781-338-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAEL PATRICK CONNELLY
Title or Position: EXECUTIVE VICE PRESIDENT, CFO
Credential:
Phone: 781-979-3028