Basic Information
| Provider Information | |||||||||
| NPI: | 1447240635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOBOTA | ||||||||
| FirstName: | JERZY | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 WRIGHT ST | ||||||||
| Address2: | DEPARTMENT OF PATHOLOGY | ||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132837651 | ||||||||
| FaxNumber: | 4132845339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 11/04/2010 | ||||||||
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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 | 207ZP0101X | 80133 | MA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0105X | 80133 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3198723 | 05 | MA | MEDICAID |