Provider Demographics
NPI:1811399025
Name:BROOKLINE DERMATOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:BROOKLINE DERMATOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARYJANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-608-1575
Mailing Address - Street 1:1208B VFW PKWY
Mailing Address - Street 2:SUTIE 200
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4349
Mailing Address - Country:US
Mailing Address - Phone:617-608-1575
Mailing Address - Fax:617-605-1576
Practice Address - Street 1:235 CYPRESS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-6776
Practice Address - Country:US
Practice Address - Phone:617-277-0800
Practice Address - Fax:617-277-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57991207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA21780Medicare PIN