Provider Demographics
NPI:1740304666
Name:LAURIE B. BOTIE, MD, PC
Entity type:Organization
Organization Name:LAURIE B. BOTIE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOTIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-453-9272
Mailing Address - Street 1:600 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1699
Mailing Address - Country:US
Mailing Address - Phone:978-453-9272
Mailing Address - Fax:978-970-1506
Practice Address - Street 1:600 CLARK RD
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1699
Practice Address - Country:US
Practice Address - Phone:978-453-9272
Practice Address - Fax:978-970-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA01-00704OtherUNITED HEALTHCARE
MA701208OtherTUFTS
MA7662OtherHARVARD PILGRIM
MA9778489Medicaid
MAM16427OtherBLUE CRS BL SHLD GROUP #
MA6727439OtherCIGNA HEALTHCARE
MA56335OtherAETNA GROUP #
NH30002667OtherMEDICAID NEW HAMPSHIRE
MAM20211Medicare ID - Type UnspecifiedMEDICARE GROUP #
MA9778489Medicaid