Healthcare Provider Details

I. General information

NPI: 1750763116
Provider Name (Legal Business Name): SUBHA BAISYAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 12/18/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 N PEARL ST
BROCKTON MA
02301-1708
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 508-408-9200
  • Fax: 857-241-5492
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number278218
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: