Healthcare Provider Details

I. General information

NPI: 1770142945
Provider Name (Legal Business Name): COMMONWEALTH MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

529 MAIN ST FL 3
CHARLESTOWN MA
02129-1125
US

V. Phone/Fax

Practice location:
  • Phone: 617-886-8264
  • Fax:
Mailing address:
  • Phone: 617-886-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARIE BONAVENTURA
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 617-886-8013