Provider Demographics
NPI:1538131867
Name:BERUBE, NANCY D (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:D
Last Name:BERUBE
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 1:121 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2429
Mailing Address - Country:US
Mailing Address - Phone:508-756-0514
Mailing Address - Fax:508-756-0843
Practice Address - Street 1:121 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2429
Practice Address - Country:US
Practice Address - Phone:508-756-0514
Practice Address - Fax:508-756-0843
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2002515Medicaid
MAY02689Medicare ID - Type Unspecified
MA2002515Medicaid