Basic Information
| Provider Information | |||||||||
| NPI: | 1841515434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINIMALLY INVASTIVE THORACIC SURGERY ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386368 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W CUMMINGS PARK | ||||||||
| Address2: | STE. 4700 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018016372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819326487 | ||||||||
| FaxNumber: | 7819326486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | PODDAR | ||||||||
| AuthorizedOfficialFirstName: | PRODYUT | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7819326487 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 110083476A | 05 | MA | MEDICAID |