=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699622134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASS GENERAL BRIGHAM MEDICAL GROUP SUBURBAN MASSACHUSETTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2026
-----------------------------------------------------
Last Update Date | 03/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 541 MAIN ST STE 420
-----------------------------------------------------
City | S WEYMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02190-1889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-952-1367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 399 REVOLUTION DR STE 580
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-726-3884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, RCO PROVIDER ENROLLMENT
-----------------------------------------------------
Name | JOANNA HAZELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-254-4854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------