Healthcare Provider Details

I. General information

NPI: 1942664818
Provider Name (Legal Business Name): COMMONWEALTH SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 MONTVALE AVE SUITE 208
STONEHAM MA
02180-3623
US

IV. Provider business mailing address

91 MONTVALE AVE SUITE 208
STONEHAM MA
02180-3623
US

V. Phone/Fax

Practice location:
  • Phone: 781-279-1123
  • Fax: 781-438-3034
Mailing address:
  • Phone: 781-279-1123
  • Fax: 781-438-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY YANNALFO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 781-279-1123