Basic Information
| Provider Information | |||||||||
| NPI: | 1720003494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAXMAN | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448254 | ||||||||
| FaxNumber: | 7817443510 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448254 | ||||||||
| FaxNumber: | 7817443510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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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 | 207RC0000X | 74500 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 74500 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 110052039A | 05 | MA | MEDICAID |