Provider Demographics
NPI:1578617445
Name:ROSLINDALE PEDIATRIC ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ROSLINDALE PEDIATRIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:STACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-522-3100
Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:31
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-522-3100
Mailing Address - Fax:617-522-6366
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:31
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-522-3100
Practice Address - Fax:617-522-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29672208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA600454OtherTUFTS
MA9757864Medicaid
MA0036005OtherNEIGHBORHOOD HLTH PLAN
MA9058OtherAETNA US HEALTHCARE
MAM14816OtherBLUE CROSS BLUE SHIELD MA
MA9757864Medicaid
MA600454OtherTUFTS