Basic Information
| Provider Information | |||||||||
| NPI: | 1821362294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODBINE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MASHPEE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5 INDUSTRIAL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026493464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084774282 | ||||||||
| FaxNumber: | 5085396134 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 INDUSTRIAL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026493464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084774282 | ||||||||
| FaxNumber: | 5085396134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARSH | ||||||||
| AuthorizedOfficialFirstName: | TEDI | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5085396188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC, CPP-P | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 51965 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.