Provider Demographics
NPI:1487794814
Name:WEST CAMBRIDGE PEDIATRIC & ADOLESCENT MEDICIN, PC
Entity type:Organization
Organization Name:WEST CAMBRIDGE PEDIATRIC & ADOLESCENT MEDICIN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-547-1995
Mailing Address - Street 1:575 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4656
Mailing Address - Country:US
Mailing Address - Phone:617-547-1421
Mailing Address - Fax:617-492-1118
Practice Address - Street 1:575 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4656
Practice Address - Country:US
Practice Address - Phone:617-547-1421
Practice Address - Fax:617-492-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49447302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE38736Medicare UPIN
MAE01875Medicare UPIN
MAI32619Medicare UPIN
MAF97292Medicare UPIN