Provider Demographics
NPI:1487700522
Name:BOULEVARD MEDICAL GROUP INC.
Entity type:Organization
Organization Name:BOULEVARD MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARSHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-762-4480
Mailing Address - Street 1:80 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1441
Mailing Address - Country:US
Mailing Address - Phone:508-762-4480
Mailing Address - Fax:508-752-1404
Practice Address - Street 1:338 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1637
Practice Address - Country:US
Practice Address - Phone:508-762-4480
Practice Address - Fax:508-752-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9764500Medicaid
MAM21412Medicare ID - Type Unspecified