Basic Information
Provider Information | |||||||||
NPI: | 1134651433 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TARABOCHIA-GAST | ||||||||
FirstName: | ALEXANDRA | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GAST | ||||||||
OtherFirstName: | ALEXANDRA | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 801 ALBANY STREET | ||||||||
Address2: | FL G | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021193791 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 W SQUANTUM ST | ||||||||
Address2: |   | ||||||||
City: | NORTH QUINCY | ||||||||
State: | MA | ||||||||
PostalCode: | 021712122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6173763000 | ||||||||
FaxNumber: | 6177441905 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2017 | ||||||||
LastUpdateDate: | 01/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 282532 | MA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110127140A | 05 | MA |   | MEDICAID | 3125582 | 05 | NH |   | MEDICAID |