Basic Information
| Provider Information | |||||||||
| NPI: | 1326202797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT AUBURN PROF SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLEEP DISORDERS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 799 CONCORD AVE | ||||||||
| Address2: | D-3 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178682914 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | NUNZIATO | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 261QS1200X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 9702580 | 05 | MA | MEDICAID |