Healthcare Provider Details

I. General information

NPI: 1013375203
Provider Name (Legal Business Name): MT AUBURN PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 CONCORD AVE SUITE 4100
CAMBRIDGE MA
02138-1040
US

IV. Provider business mailing address

1 ARSENAL MARKET PL
WATERTOWN MA
02472-5018
US

V. Phone/Fax

Practice location:
  • Phone: 617-864-8822
  • Fax: 617-547-5367
Mailing address:
  • Phone: 617-673-1851
  • Fax: 617-499-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN SMITH
Title or Position: CFO
Credential:
Phone: 405-245-6238