Provider Demographics
NPI:1053393603
Name:WINCHESTER PHYSICIAN ASSOCIATES
Entity type:Organization
Organization Name:WINCHESTER PHYSICIAN ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-756-7273
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4260
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-756-7274
Practice Address - Street 1:75 RIVERSIDE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4600
Practice Address - Country:US
Practice Address - Phone:781-396-3701
Practice Address - Fax:781-396-7716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINCHESTER PHYSICIAN ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-18
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54808207R00000X
MA76266207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9777229Medicaid
MA9777229Medicaid