Healthcare Provider Details

I. General information

NPI: 1841686219
Provider Name (Legal Business Name): LIBERTY REFORMA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2015
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVENUE, FL 5 YAWKEY BLDG
BOSTON MA
02118-4001
US

IV. Provider business mailing address

801 ALBANY STREET FL GROUND
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number278216
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number278216
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: