Healthcare Provider Details

I. General information

NPI: 1417401993
Provider Name (Legal Business Name): EDYTA M KONRAD MD, PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BOLTON ST OFIICE # 100
MARLBOROUGH MA
01752-3988
US

IV. Provider business mailing address

320 BOLTON ST OFIICE # 100
MARLBOROUGH MA
01752-3988
US

V. Phone/Fax

Practice location:
  • Phone: 508-460-6002
  • Fax: 508-460-6028
Mailing address:
  • Phone: 508-460-6002
  • Fax: 508-460-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number157585
License Number StateMA

VIII. Authorized Official

Name: DR. EDYTA MARIA KONRAD
Title or Position: OWNER
Credential: MD, PHD
Phone: 508-460-6002