Provider Demographics
NPI:1174545875
Name:MASS GENERAL BRIGHAM COMMUNITY PHYSICIANS INC.
Entity type:Organization
Organization Name:MASS GENERAL BRIGHAM COMMUNITY PHYSICIANS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, SVP OF ADMIN & TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-282-2028
Mailing Address - Street 1:399 REVOLUTION DR STE 1010
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1582
Mailing Address - Country:US
Mailing Address - Phone:857-282-2063
Mailing Address - Fax:
Practice Address - Street 1:80 BEHARRELL ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-1739
Practice Address - Country:US
Practice Address - Phone:781-259-9292
Practice Address - Fax:781-259-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA43554207RP1001X
MA75595207RR0500X
MA59966207RA0000X
MA24941207RC0000X
MA59897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9777563Medicaid
MAWEB14101Medicare ID - Type UnspecifiedDR. LYNN B. WEIGEL
MAD88529Medicare UPIN
MAF51176Medicare UPIN
MAJ13485Medicare ID - Type UnspecifiedDR. PAMELA DELUCA
MAA34278Medicare UPIN
MA9777563Medicaid
MAHOJ10543Medicare ID - Type UnspecifiedDR. PETER A. HOENIG
MAE69468Medicare UPIN
MAKEMO3691Medicare ID - Type UnspecifiedDR. CHARLES S. KEEVIL
MAJO8172Medicare ID - Type UnspecifiedDR. MARGUERITE C. ROACH