Provider Demographics
NPI:1568404903
Name:BOSTON PLASTIC & ORAL SURGERY
Entity Type:Organization
Organization Name:BOSTON PLASTIC & ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MEARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-355-7252
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:HU-158
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-7252
Mailing Address - Fax:617-738-1657
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:HU-158
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-7252
Practice Address - Fax:617-738-1657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9704230Medicaid
MAG39274Medicare UPIN
MAM20977Medicare ID - Type Unspecified