Healthcare Provider Details

I. General information

NPI: 1225332885
Provider Name (Legal Business Name): MAESTRO OUTREACH MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 S UNION ST BUILDING 2, SUITE # 107
LAWRENCE MA
01843-2837
US

IV. Provider business mailing address

439 S UNION ST BUILDING 2, SUITE # 107
LAWRENCE MA
01843-2837
US

V. Phone/Fax

Practice location:
  • Phone: 978-794-1158
  • Fax: 978-794-1507
Mailing address:
  • Phone: 978-794-1158
  • Fax: 978-794-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code364SP0811X
TaxonomyChronically Ill Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE M KIONGERA
Title or Position: PRESIDENT & CHIEF EXECUTIVE OFFICER
Credential: NP
Phone: 978-973-3749