=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063805687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUFTS MEDICAL CENTER COMMUNITY CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2015
-----------------------------------------------------
Last Update Date | 09/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 WOOD RD SUITE 210
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-356-3336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 WOOD RD SUITE 210
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-356-3336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | NATHAN J. GAGNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-356-3336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------