Provider Demographics
NPI:1083788756
Name:REVERE WINTHROP PEDIATRICS
Entity Type:Organization
Organization Name:REVERE WINTHROP PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AILISH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-289-5057
Mailing Address - Street 1:280 BEACH STREET
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:781-289-5057
Mailing Address - Fax:781-289-4485
Practice Address - Street 1:280 BEACH STREET
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-289-5057
Practice Address - Fax:781-289-4485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04089Medicare PIN