Basic Information
| Provider Information | |||||||||
| NPI: | 1790730539 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MELROSE WAKEFIELD EMERGENCY PHYSICIANS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 OAK PARK DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801736 | ||||||||
| FaxNumber: | 7812766404 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021763225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801736 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | ELIJAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7812801500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9785205 | 05 | MA | MEDICAID | M17231 | 01 | MA | BCBS | OTHER |