Provider Demographics
NPI:1174941884
Name:BOSTON MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BOSTON MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:QUOC
Authorized Official - Middle Name:H
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-735-8451
Mailing Address - Street 1:1001 N. LAKE DESTINY DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-951-8795
Mailing Address - Fax:407-951-8796
Practice Address - Street 1:1001 N. LAKE DESTINY DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:407-951-8795
Practice Address - Fax:407-951-8796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty