Basic Information
| Provider Information | |||||||||
| NPI: | 1437196359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CARE OF BOSTON MANAGEMENT CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 BLUE HILL DR | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177541023 | ||||||||
| FaxNumber: | 6177541040 | ||||||||
| Practice Location | |||||||||
| Address1: | 464 HILLSIDE AVE | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024941227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177540730 | ||||||||
| FaxNumber: | 6177540731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTOFORO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6177540745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9780378 | 05 | MA | MEDICAID |