Healthcare Provider Details

I. General information

NPI: 1275650814
Provider Name (Legal Business Name): TAMARA LYNNE ROUSSEAU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 LINCOLN ST DEPT. OF PEDIATRICS-4TH FLOOR
FRAMINGHAM MA
01702-6358
US

IV. Provider business mailing address

115 LINCOLN ST DEPT. OF PEDIATRICS-4TH FLOOR
FRAMINGHAM MA
01702-6358
US

V. Phone/Fax

Practice location:
  • Phone: 508-383-8740
  • Fax:
Mailing address:
  • Phone: 508-383-8740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number229310
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: