Basic Information
| Provider Information | |||||||||
| NPI: | 1336671882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MASSACHUSETTS EYE AND EAR ASSOCIATES NORTH SUBURBAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 243 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175237900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 243 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175237900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2017 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCULLY | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING | ||||||||
| AuthorizedOfficialTelephone: | 6175734034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MASSACHUSETTS EYE AND EAR ASSOCIATES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.