Healthcare Provider Details

I. General information

NPI: 1669588372
Provider Name (Legal Business Name): MEDIGROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FRANK LEARY WAY
RANDOLPH MA
02368-4512
US

IV. Provider business mailing address

4 FRANK LEARY WAY
RANDOLPH MA
02368-4512
US

V. Phone/Fax

Practice location:
  • Phone: 781-986-1737
  • Fax: 781-986-0507
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number54262
License Number StateMA

VIII. Authorized Official

Name: DR. MARK WEINER
Title or Position: OWNER
Credential: M.D.
Phone: 781-986-1737