Provider Demographics
NPI:1063646008
Name:MINIMALLY INVASIVE THORACIC SURGERY ASSOCIATES, PC
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE THORACIC SURGERY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRODUYT
Authorized Official - Middle Name:K
Authorized Official - Last Name:PODDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-257-5945
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:SUITE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-454-3566
Mailing Address - Fax:508-438-6368
Practice Address - Street 1:800 W CUMMINGS PARK
Practice Address - Street 2:SUITE 4700
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6372
Practice Address - Country:US
Practice Address - Phone:781-932-6487
Practice Address - Fax:781-932-6486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19736OtherBCBS
MA110083476AMedicaid
MA110083476AMedicaid