Basic Information
| Provider Information | |||||||||
| NPI: | 1467834168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISBACH | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | SEMINE | ||||||||
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| OtherLastName: | SEMINE | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | ALEXANDRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 ALBANY ST FL G | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021193791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 840 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176386610 | ||||||||
| FaxNumber: | 6176386616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 287025 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 110108751A | 05 | MA | MEDICAID | 3131428 | 05 | NH | MEDICAID |