Basic Information
| Provider Information | |||||||||
| NPI: | 1508846163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORE PHYSICIAN SERVICES OF MASSACHUSETTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 367 | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035806009 | ||||||||
| FaxNumber: | 6035807952 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 LINCOLN AVENUE | ||||||||
| Address2: | |||||||||
| City: | HAVERHILL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785213676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CRESTA | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6035806693 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9737456 | 05 | MA | MEDICAID |