Healthcare Provider Details

I. General information

NPI: 1700215670
Provider Name (Legal Business Name): NEW ENGLAND REPRODUCTIVE MEDICINE AND SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 WEST ST SUITE 25
MILLBURY MA
01527-2622
US

IV. Provider business mailing address

22 WEST ST STE 25
MILLBURY MA
01527-2677
US

V. Phone/Fax

Practice location:
  • Phone: 508-238-8646
  • Fax:
Mailing address:
  • Phone: 508-917-6720
  • Fax: 508-917-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number226853
License Number StateMA

VIII. Authorized Official

Name: BRIAN CLARK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 508-917-3720