=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922367168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGWOOD ACADEMIC PHYSICIANS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2012
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 198 GROTON RD SUITE 2
-----------------------------------------------------
City | AYER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01432-1177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-772-3793
-----------------------------------------------------
Fax | 978-772-3797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 198 GROTON RD SUITE 2
-----------------------------------------------------
City | AYER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01432-1177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-772-3793
-----------------------------------------------------
Fax | 978-772-3797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF NETWORK OPERATIONS
-----------------------------------------------------
Name | JOHN DIGIORGIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-632-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | 76993
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 76993
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------