Provider Demographics
NPI:1144311069
Name:METRO WEST DERMATOLOGY
Entity type:Organization
Organization Name:METRO WEST DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-879-8128
Mailing Address - Street 1:140 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6306
Mailing Address - Country:US
Mailing Address - Phone:508-879-8128
Mailing Address - Fax:508-879-3837
Practice Address - Street 1:140 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6306
Practice Address - Country:US
Practice Address - Phone:508-879-8128
Practice Address - Fax:508-879-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52195207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4121OtherHARVARD PILGRIM HEALTH
54737OtherFALLON SELECT & DIRECT
MA709234OtherTUFTS
MAJ03757OtherBCBS
0004684OtherNEIGHBORHOOD HEALTH PLAN
54737OtherFALLON SELECT & DIRECT
MAV03192Medicare ID - Type Unspecified