Basic Information
| Provider Information | |||||||||
| NPI: | 1386665321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEITH | ||||||||
| FirstName: | AGNIESZKA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | LAHEY CLINIC INC | ||||||||
| Address2: | 41 MALL ROAD | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | 9789211254 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 CONANT ST | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789271919 | ||||||||
| FaxNumber: | 9789211254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 216580 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110033820A | 05 | MA | MEDICAID |