Provider Demographics
NPI:1487636130
Name:BIRGENEAU, PATRICIA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:BIRGENEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:BIRGENEAU
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:80 BAKER AVENUE EXTENSION
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:978-287-9402
Mailing Address - Fax:978-287-9408
Practice Address - Street 1:80 BAKER AVE. EXTENSION
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:978-287-9402
Practice Address - Fax:978-287-9408
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211830208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2087740Medicaid
MA2087740Medicaid
PRA37902Medicare ID - Type Unspecified