=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447584859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONALIZED PREVENTIVE MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2009
-----------------------------------------------------
Last Update Date | 09/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 REEDSDALE RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02186-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-698-0715
-----------------------------------------------------
Fax | 617-698-7559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 REEDSDALE RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02186-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-698-0715
-----------------------------------------------------
Fax | 617-698-7559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D., F.A.C.C
-----------------------------------------------------
Name | DR. RICHARD M DELANY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 617-698-0715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 44038
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------