Provider Demographics
NPI:1295046647
Name:FEDERAL MEDICAL CENTER DEVENS
Entity type:Organization
Organization Name:FEDERAL MEDICAL CENTER DEVENS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSIST HEALTH SERVICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-796-1400
Mailing Address - Street 1:35 OAK KNOLL RD
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1103
Mailing Address - Country:US
Mailing Address - Phone:508-545-0733
Mailing Address - Fax:
Practice Address - Street 1:42 PATTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01433
Practice Address - Country:US
Practice Address - Phone:978-796-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA2382261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA2382OtherSTATE PHYSICIAN ASSISTANT LICENSE