Healthcare Provider Details

I. General information

NPI: 1174797575
Provider Name (Legal Business Name): BETH A DRZEWIECKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-5631
  • Fax:
Mailing address:
  • Phone: 617-724-5631
  • Fax: 617-726-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number289327
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: