Provider Demographics
NPI:1407865439
Name:MT AUBURN PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:MT AUBURN PROFESSIONAL SERVICES
Other - Org Name:MT AUBURN PROFESSIONAL OBGYN
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:617-499-5644
Mailing Address - Fax:617-499-5620
Practice Address - Street 1:ONE ARSENAL MARKETPLACE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:617-673-1851
Practice Address - Fax:617-499-5579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X, 207VX0201X
MA208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078204BMedicaid
MA603257OtherTUFTS
MAM17630OtherBLUE CROSS BLUE SHIELD
MA110078204BMedicaid