Provider Demographics
NPI:1174052351
Name:WALPOLE MEDICAL CENTER, PC
Entity type:Organization
Organization Name:WALPOLE MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERHANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-668-6600
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-0426
Mailing Address - Country:US
Mailing Address - Phone:508-807-4265
Mailing Address - Fax:508-807-4267
Practice Address - Street 1:1428 MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1729
Practice Address - Country:US
Practice Address - Phone:508-668-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095599AMedicaid