Provider Demographics
NPI:1528240751
Name:PRATT MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PRATT MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-636-5410
Mailing Address - Street 1:PO BOX 11218
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02211-1218
Mailing Address - Country:US
Mailing Address - Phone:617-636-2546
Mailing Address - Fax:
Practice Address - Street 1:873 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-3714
Practice Address - Country:US
Practice Address - Phone:617-636-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRATT MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-29
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASF063069OtherBCBS MA
MASF063069OtherBCBS MA