Provider Demographics
NPI:1255674636
Name:MT AUBURN PROF SERVICES
Entity type:Organization
Organization Name:MT AUBURN PROF SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-245-6238
Mailing Address - Street 1:ONE ARSENAL MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2861
Mailing Address - Country:US
Mailing Address - Phone:617-673-1851
Mailing Address - Fax:617-499-5579
Practice Address - Street 1:ONE ARSENAL MARKETPLACE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2861
Practice Address - Country:US
Practice Address - Phone:617-673-1851
Practice Address - Fax:617-499-5579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078204CMedicaid
MA603255OtherTUFTS
MAM14923Medicare PIN