Healthcare Provider Details

I. General information

NPI: 1215913926
Provider Name (Legal Business Name): HOLLY ROTHERMEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST YAW 6, PEDIATRIC GROUP PRACTICE
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2728
  • Fax: 617-726-3948
Mailing address:
  • Phone: 617-726-2728
  • Fax: 617-724-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number150450
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number150450
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: