Basic Information
| Provider Information | |||||||||
| NPI: | 1255674636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT AUBURN PROF SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE ARSENAL MARKETPLACE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024722861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE ARSENAL MARKETPLACE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024722861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | NUNZIATO | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6176731851 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 603255 | 01 | MA | TUFTS | OTHER | 110078204C | 05 | MA | MEDICAID |