1124651658 NPI number — DR. MADELEINE SERTIC

Table of content: DR. MADELEINE SERTIC (NPI 1124651658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124651658 NPI number — DR. MADELEINE SERTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERTIC
Provider First Name:
MADELEINE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124651658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/08/2020
NPI Reactivation Date:
12/15/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DIVISION OF ABDOMINAL IMAGING, DEPARTMENT OF RADIOLOGY,
Provider Second Line Business Mailing Address:
55 FRUIT STREET, WHITE 270
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-643-2009
Provider Business Mailing Address Fax Number:
617-726-4891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DIVISION OF ABDOMINAL IMAGING, DEPARTMENT OF RADIOLOGY,
Provider Second Line Business Practice Location Address:
55 FRUIT STREET, WHITE 270
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-643-2009
Provider Business Practice Location Address Fax Number:
617-726-4891
Provider Enumeration Date:
02/12/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  286998 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)