Basic Information
| Provider Information | |||||||||
| NPI: | 1184867483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELMONT MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 CONCORD AVE | ||||||||
| Address2: | SUITE 4100 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178644108 | ||||||||
| FaxNumber: | 6175475367 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 CONCORD AVE | ||||||||
| Address2: | SUITE 4100 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178644108 | ||||||||
| FaxNumber: | 6175475367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2009 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | CONNORS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6178644108 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BELMONT MEDICAL ASSOCIATES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 47577 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VG0400X | 56978 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | M12887 | 01 | MA | BLUE CROSS BLUE SHIELD OF MASSACHUSETTS | OTHER |