Healthcare Provider Details

I. General information

NPI: 1669696530
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 WASHINGTON ST 2ND FLOOR
WEYMOUTH MA
02189-1530
US

IV. Provider business mailing address

884 WASHINGTON ST 2ND FLOOR
WEYMOUTH MA
02189-1530
US

V. Phone/Fax

Practice location:
  • Phone: 617-447-2146
  • Fax: 617-259-1627
Mailing address:
  • Phone: 617-447-2146
  • Fax: 617-259-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY J DELONG
Title or Position: CREDENTIALING MANAGER
Credential: MM, RHIA
Phone: 413-222-7711