Healthcare Provider Details

I. General information

NPI: 1356554992
Provider Name (Legal Business Name): BROOKLINE VILLAGE OBGYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PL SUITE 521
BROOKLINE MA
02445-7224
US

IV. Provider business mailing address

1 BROOKLINE PL SUITE 521
BROOKLINE MA
02445-7224
US

V. Phone/Fax

Practice location:
  • Phone: 617-735-8800
  • Fax: 617-278-9358
Mailing address:
  • Phone: 617-735-8800
  • Fax: 617-278-9358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PHYLLIS C KATZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 617-735-8800