Provider Demographics
NPI:1902853468
Name:HERITAGE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:HERITAGE MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANZILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-837-7141
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-0489
Mailing Address - Country:US
Mailing Address - Phone:800-720-1664
Mailing Address - Fax:207-753-2020
Practice Address - Street 1:280 HERITAGE PARK
Practice Address - Street 2:HERITAGE MEDICAL GROUP
Practice Address - City:SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02563
Practice Address - Country:US
Practice Address - Phone:781-827-7141
Practice Address - Fax:781-834-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0220OtherRAILROAD MEDICARE
MA9739050Medicaid
MAM21464Medicare PIN