Basic Information
| Provider Information | |||||||||
| NPI: | 1114979580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MCLEAN HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCLEAN PROFESSIONAL PRACTICE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 5-0397 | ||||||||
| Address2: | |||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018150397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178552183 | ||||||||
| FaxNumber: | 6178553745 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 MILL ST | ||||||||
| Address2: | |||||||||
| City: | BELMONT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024781041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178552183 | ||||||||
| FaxNumber: | 6178553745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | GOLD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6178552367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 9778705 | 05 | MA | MEDICAID | M16400 | 01 | MA | BC/BS | OTHER | 1201174 | 05 | MA | MEDICAID | W10374 | 01 | MA | BC/BS | OTHER |