Provider Demographics
NPI:1962686816
Name:MT AUBURN PROFESSIONAL SERVICE
Entity Type:Organization
Organization Name:MT AUBURN PROFESSIONAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKASIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-499-5675
Mailing Address - Street 1:ONE ARSENAL MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-673-1851
Mailing Address - Fax:617-499-5579
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:STE 110
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4540
Practice Address - Country:US
Practice Address - Phone:781-396-4514
Practice Address - Fax:781-322-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19292OtherBLUE CROSS