Basic Information
| Provider Information | |||||||||
| NPI: | 1386608974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKIEWICZ | ||||||||
| FirstName: | HENRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 690 CANTON STREET | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172984632 | ||||||||
| FaxNumber: | 6172966919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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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 | 207L00000X | 216399 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2012821 | 05 | MA | MEDICAID |