Healthcare Provider Details

I. General information

NPI: 1124136510
Provider Name (Legal Business Name): WOBURN PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ALFRED ST BALDWIN PARK II
WOBURN MA
01801-1976
US

IV. Provider business mailing address

7 ALFRED ST BALDWIN PARK II
WOBURN MA
01801-1976
US

V. Phone/Fax

Practice location:
  • Phone: 781-933-6236
  • Fax: 781-938-8050
Mailing address:
  • Phone: 781-933-6236
  • Fax: 781-938-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9712623
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier25114
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerFALLON
# 3
Identifier805422
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS HEALTH PLAN - LAB
# 4
IdentifierM12470
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS BLUE SHIELD
# 5
Identifier600388
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS HEALTH PLAN
# 6
Identifier9110
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerAETNA/US HEALTHCARE

VIII. Authorized Official

Name: JOHN PETRARCA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 781-638-1020