Healthcare Provider Details

I. General information

NPI: 1245440726
Provider Name (Legal Business Name): MMDS OF BOSTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SILVER LAKE AVE.
NEWTON MA
02458-1111
US

IV. Provider business mailing address

48 SILVER LAKE AVE.
NEWTON MA
02458-1111
US

V. Phone/Fax

Practice location:
  • Phone: 617-244-9729
  • Fax:
Mailing address:
  • Phone: 617-244-9729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD SCOTT GRINLEY
Title or Position: PRESIDENT, CEO
Credential: M.ED.
Phone: 617-244-9729