1669658712 NPI number — TUFTS UNIVERSITY HEALTH SERVICE

Table of content: MARIANNE BOUTROS PA-C (NPI 1215740501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669658712 NPI number — TUFTS UNIVERSITY HEALTH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUFTS UNIVERSITY HEALTH SERVICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1669658712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 PROFESSORS ROW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-5816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-627-3350
Provider Business Mailing Address Fax Number:
617-627-3592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 PROFESSORS ROW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-5816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-627-3350
Provider Business Practice Location Address Fax Number:
617-627-3592
Provider Enumeration Date:
01/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CAGGIANO
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
617-627-3350

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , 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)





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