Provider Demographics
NPI:1134191208
Name:SIROKY, MIKE B (MD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:B
Last Name:SIROKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-8485
Practice Address - Fax:617-638-8487
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33777208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2042053Medicaid
MAA35572Medicare UPIN
MA2042053Medicaid