Provider Demographics
NPI:1629502703
Name:HOSSEINI, MARYAM
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:HOSSEINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST # 306
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-5172
Mailing Address - Fax:617-636-5178
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:DEPARTMENT OF MEDICINE , 5TH FLOOR
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-618-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA2913752081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1629502703Medicaid