Healthcare Provider Details

I. General information

NPI: 1619034410
Provider Name (Legal Business Name): WILLOW STREET FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 ASBURY ST
SOUTH HAMILTON MA
01982-1808
US

IV. Provider business mailing address

42 ASBURY ST
SOUTH HAMILTON MA
01982-1808
US

V. Phone/Fax

Practice location:
  • Phone: 978-468-4101
  • Fax:
Mailing address:
  • Phone: 978-468-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70411
License Number StateMA

VIII. Authorized Official

Name: BRUCE W SMITH
Title or Position: OWNER
Credential: M.D.
Phone: 978-468-4101