Basic Information
| Provider Information | |||||||||
| NPI: | 1922118439 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY PRACTICE GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 22 MILL ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024764784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816489700 | ||||||||
| FaxNumber: | 7816480234 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MILL ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024764784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816489700 | ||||||||
| FaxNumber: | 7816480234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALTMAN | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7816489700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 9711635 | 05 | MA | MEDICAID |