Basic Information
| Provider Information | |||||||||
| NPI: | 1164834750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHBORO MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | 5084603025 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | 5084603025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2014 | ||||||||
| LastUpdateDate: | 05/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | LABOSSIERE | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5084603297 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.