=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376709683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL MEDICINE AND ENDOCRINOLOGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2008
-----------------------------------------------------
Last Update Date | 08/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 PARK AVE SUITE 210
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-754-8000
-----------------------------------------------------
Fax | 508-752-8286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 PARK AVE SUITE 210
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-754-8000
-----------------------------------------------------
Fax | 508-752-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JOHN PAUL LOCK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 508-754-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 35925
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------