Basic Information
| Provider Information | |||||||||
| NPI: | 1720112865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAIN STREET PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOPKINTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017481684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084355506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOPKINTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017481684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084355506 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BASOW | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DREW | ||||||||
| AuthorizedOfficialTitleorPosition: | PART OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5084355506 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.