Healthcare Provider Details

I. General information

NPI: 1326350976
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COGGESHALL ST
NEW BEDFORD MA
02746-1923
US

IV. Provider business mailing address

360 COGGESHALL ST
NEW BEDFORD MA
02746-1923
US

V. Phone/Fax

Practice location:
  • Phone: 774-328-9629
  • Fax: 774-328-9634
Mailing address:
  • Phone: 774-328-9629
  • Fax: 774-328-9634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY J DELONG
Title or Position: CREDENTIALING MANAGER
Credential: MM, RHIA
Phone: 413-222-7711