Basic Information
| Provider Information | |||||||||
| NPI: | 1164640306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT AUBURN PROFESSIONAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE ARSENAL MARKETPLACE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE ARSENAL MARKETPLACE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | PALUMBO | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6176731851 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 604027 | 01 | MA | TUFTS GROUP | OTHER |