Healthcare Provider Details

I. General information

NPI: 1376525311
Provider Name (Legal Business Name): VICKI ELLEN MODEST MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKI ELLEN MODEST MD

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST CLN 3
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIANS ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3030
  • Fax: 617-726-7536
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number153069
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: