1700535507 NPI number — DR. MARC DOMINA BEAUDIN MD, PHD

Table of content: DR. MARC DOMINA BEAUDIN MD, PHD (NPI 1700535507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700535507 NPI number — DR. MARC DOMINA BEAUDIN MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUDIN
Provider First Name:
MARC
Provider Middle Name:
DOMINA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
M

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:
1700535507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 AUBURN ST APT 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALDEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02148-4056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-669-4319
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 HARRISON AVE
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PEDIATRICS, DOWLING 3 SOUTH
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-669-4319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2022

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: 390200000X , 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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