Basic Information
Provider Information | |||||||||
NPI: | 1962686816 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MT AUBURN PROFESSIONAL SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ONE ARSENAL MARKETPLACE | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | MA | ||||||||
PostalCode: | 02472 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176731851 | ||||||||
FaxNumber: | 6174995579 | ||||||||
Practice Location | |||||||||
Address1: | 101 MAIN ST | ||||||||
Address2: | STE 110 | ||||||||
City: | MEDFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 021554540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7813964514 | ||||||||
FaxNumber: | 7813221394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2007 | ||||||||
LastUpdateDate: | 12/27/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUKASIK | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 6174995675 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | M19292 | 01 | MA | BLUE CROSS | OTHER |