Basic Information
| Provider Information | |||||||||
| NPI: | 1801810213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GEMINI MEDICAL LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019153012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/18/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERING | ||||||||
| AuthorizedOfficialFirstName: | HARRIET | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9789274110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 291U00000X | 2474 | MA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0804436 | 05 | MA | MEDICAID | M16434 | 01 | MA | BS | OTHER | 63095 | 01 | AETNA | OTHER | 228316 | 01 | MA | MEDICARE | OTHER |