Healthcare Provider Details

I. General information

NPI: 1851597306
Provider Name (Legal Business Name): SOUTHBORO MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

IV. Provider business mailing address

24 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

V. Phone/Fax

Practice location:
  • Phone: 508-481-5500
  • Fax: 508-460-3025
Mailing address:
  • Phone: 508-481-5500
  • Fax: 508-460-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARVIN OSTROVSKY
Title or Position: PRESIDENT
Credential: MD
Phone: 508-481-5500