Healthcare Provider Details

I. General information

NPI: 1346222064
Provider Name (Legal Business Name): STONEHAM MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 MONTVALE AVE 2
STONEHAM MA
02180-3643
US

IV. Provider business mailing address

PO BOX 760
WINCHESTER MA
01890-4260
US

V. Phone/Fax

Practice location:
  • Phone: 781-481-9255
  • Fax: 781-481-9257
Mailing address:
  • Phone: 781-756-7273
  • Fax: 781-721-0725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number152386
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number206855
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52067
License Number StateMA

VIII. Authorized Official

Name: EILEEN WILLS
Title or Position: BILLING MANAGER
Credential:
Phone: 781-756-7273