Basic Information
| Provider Information | |||||||||
| NPI: | 1407840242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADIAS | ||||||||
| FirstName: | NICOLAOS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | RM 339 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625359 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 NEVINS ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177796700 | ||||||||
| FaxNumber: | 6177796771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 60637 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0164461 | 05 | MA | MEDICAID |