Healthcare Provider Details

I. General information

NPI: 1720112865
Provider Name (Legal Business Name): MAIN STREET PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W MAIN ST
HOPKINTON MA
01748-1684
US

IV. Provider business mailing address

77 W MAIN ST
HOPKINTON MA
01748-1684
US

V. Phone/Fax

Practice location:
  • Phone: 508-435-5506
  • Fax:
Mailing address:
  • Phone: 508-435-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMA

VIII. Authorized Official

Name: DR. ROBERT DREW BASOW
Title or Position: PART OWNER
Credential: MD
Phone: 508-435-5506