Healthcare Provider Details

I. General information

NPI: 1912052853
Provider Name (Legal Business Name): SPENCER MEAD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

475 WASHINGTON ST
NEWTON MA
02458-1450
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1000
  • Fax:
Mailing address:
  • Phone: 617-823-5154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0563P
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1575
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: