Provider Demographics
NPI:1982642559
Name:STRACCIOLINI, ANDREA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:STRACCIOLINI
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 1:319 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5728
Mailing Address - Country:US
Mailing Address - Phone:617-355-6028
Mailing Address - Fax:617-731-5298
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-355-6028
Practice Address - Fax:617-731-5298
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153377208000000X, 2080P0204X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3193230Medicaid
H13439Medicare UPIN
A3082201Medicare PIN
STA30822Medicare ID - Type Unspecified