Basic Information
Provider Information | |||||||||
NPI: | 1346599420 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUVOROV | ||||||||
FirstName: | TATIANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SAUNDERS | ||||||||
OtherFirstName: | TATIANA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | CAMBRIDGE HEALTH ALLIANCE | ||||||||
Address2: | 1493 CAMBRIDGE STREET | ||||||||
City: | CAMBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 02139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176651000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CHA REVERE FAMILY CARE CENTER | ||||||||
Address2: | 454 BROADWAY | ||||||||
City: | REVERE | ||||||||
State: | MA | ||||||||
PostalCode: | 02151 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7814858222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2012 | ||||||||
LastUpdateDate: | 06/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA6778 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 015788 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.