Provider Demographics
NPI:1861448797
Name:MASSACHUSETTS MOBILE PET PC
Entity type:Organization
Organization Name:MASSACHUSETTS MOBILE PET PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-933-9311
Mailing Address - Street 1:35 NEW ENGLAND BUSINESS CENTER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1080
Mailing Address - Country:US
Mailing Address - Phone:978-933-9302
Mailing Address - Fax:978-933-7820
Practice Address - Street 1:140 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6700
Practice Address - Country:US
Practice Address - Phone:978-689-4738
Practice Address - Fax:978-682-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44-0373261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
706023OtherHARVARD PILGRIM
M18139OtherBLUE CROSS OF MA
0032507OtherNEIGHBORHOOD HEALTH
MA972781Medicaid
696200OtherTUFTS
3137889OtherAETNA
MA972781Medicaid