Healthcare Provider Details

I. General information

NPI: 1891822243
Provider Name (Legal Business Name): REBECCA ANN KONIECZNY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 LOWELL ST
ANDOVER MA
01810
US

IV. Provider business mailing address

323 LOWELL ST
ANDOVER MA
01810-4501
US

V. Phone/Fax

Practice location:
  • Phone: 978-783-5000
  • Fax: 978-313-8180
Mailing address:
  • Phone: 978-783-5000
  • Fax: 978-313-8180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number240048
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: