Provider Demographics
NPI:1538184692
Name:HOLLISTONPEDIATRIC GROUP
Entity type:Organization
Organization Name:HOLLISTONPEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-478-5996
Mailing Address - Street 1:100 JEFFREY AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746
Mailing Address - Country:US
Mailing Address - Phone:508-478-5996
Mailing Address - Fax:508-482-9147
Practice Address - Street 1:100 JEFFREY AVE
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-2028
Practice Address - Country:US
Practice Address - Phone:508-478-5996
Practice Address - Fax:508-482-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9749403Medicaid
MA701376OtherTUFTS HEALTH PLAN
MAM10882OtherBLUE CROSS BLUE SHIELD