Healthcare Provider Details

I. General information

NPI: 1417955402
Provider Name (Legal Business Name): BOSTON PLASTIC SURGERY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 CENTRE ST SUITE 5790
BOSTON MA
02130-3446
US

IV. Provider business mailing address

340 MAIN ST STE. 670
WORCESTER MA
01608-1604
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-0008
  • Fax: 617-522-2587
Mailing address:
  • Phone: 508-754-3566
  • Fax: 508-438-6364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ELEANOR C PITTS
Title or Position: PRESIDENT
Credential: MD
Phone: 617-522-0008