Basic Information
| Provider Information | |||||||||
| NPI: | 1174513204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARITAS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3994 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022413994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625338 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 CAMBRIDGE ST | ||||||||
| Address2: | CARITAS CHRISTI PHYSICIANS NETWORK | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021352907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625338 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | CROWLEY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VP OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6175625338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 737829 | 01 | MA | TUFTS | OTHER | 9773746 | 05 | MA | MEDICAID |