Provider Demographics
NPI:1174729628
Name:DERMATOLOGY CONSULTANTS AT NEWTON-WELLESLEY PC
Entity type:Organization
Organization Name:DERMATOLOGY CONSULTANTS AT NEWTON-WELLESLEY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:RENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-969-0210
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:B120
Mailing Address - City:NEWTON LOWER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1602
Mailing Address - Country:US
Mailing Address - Phone:617-969-0210
Mailing Address - Fax:617-527-6019
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:B120
Practice Address - City:NEWTON LOWER FALLS
Practice Address - State:MA
Practice Address - Zip Code:02462-1602
Practice Address - Country:US
Practice Address - Phone:617-969-0210
Practice Address - Fax:617-527-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36142207NS0135X
207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773479Medicaid
MA3012883Medicaid
MA9773479Medicaid
MA3012883Medicaid
MAB33410Medicare ID - Type UnspecifiedSINGLE PROVIDER