Provider Demographics
NPI:1336120815
Name:CIBOTTI GRANOF, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:CIBOTTI GRANOF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TREMONT STREET 6TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108
Mailing Address - Country:US
Mailing Address - Phone:617-454-4672
Mailing Address - Fax:617-701-7740
Practice Address - Street 1:287 MIDDLESEX AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5056
Practice Address - Country:US
Practice Address - Phone:781-222-3033
Practice Address - Fax:781-281-9927
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80891207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA080891OtherTUFTS HEALTH PLAN
MA3136922Medicaid
MAJ31154OtherBCBS MA
G01570Medicare UPIN
MAJ31154Medicare PIN