MEDICARE: MEDICAL CENTER OF GREATER MATTAPAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144425059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL CENTER OF GREATER MATTAPAN

Provider Business Mailing Address
First Line	:	1603 BLUE HILL AVE
Second Line	:
City	:	MATTAPAN
State	:	MA
Zip	:	02126-2122
Country	:	US
Telephone Number	:	617-296-5710
Fax Number	:	617-296-6368

Provider Business Practice Location Address
First Line	:	1603 BLUE HILL AVE
Second Line	:
City	:	MATTAPAN
State	:	MA
Zip	:	02126-2122
Country	:	US
Telephone Number	:	617-296-5710
Fax Number	:	617-296-6368

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RUBEN OGANESOV
Credential	:	M.D.
Telephone Number	:	617-783-5783

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	08/22/2020

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Directions to “MEDICAL CENTER OF GREATER MATTAPAN ” Practice Location

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