Healthcare Provider Details

I. General information

NPI: 1124490701
Provider Name (Legal Business Name): LEXINGTON PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BEDFORD ST STE 100
LEXINGTON MA
02420-4550
US

IV. Provider business mailing address

57 BEDFORD ST STE 100
LEXINGTON MA
02420-4550
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-4110
  • Fax: 781-863-2007
Mailing address:
  • Phone: 781-862-4110
  • Fax: 781-863-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RAMEY HARRIS-TATAR
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 781-862-4110