Provider Demographics
NPI:1326202797
Name:MT AUBURN PROF SERVICES
Entity Type:Organization
Organization Name:MT AUBURN PROF SERVICES
Other - Org Name:SLEEP DISORDERS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNZIATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-673-1851
Mailing Address - Street 1:ONE ARSENAL MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-673-1851
Mailing Address - Fax:617-499-5579
Practice Address - Street 1:799 CONCORD AVE
Practice Address - Street 2:D-3
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1048
Practice Address - Country:US
Practice Address - Phone:617-868-2914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9702580Medicaid
MA327124Medicare PIN