Healthcare Provider Details

I. General information

NPI: 1063642569
Provider Name (Legal Business Name): ANTONIA M URDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GOVERNORS AVE
MEDFORD MA
02155-1644
US

IV. Provider business mailing address

200 GOVERNORS AVE
MEDFORD MA
02155-1644
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-5400
  • Fax: 781-396-0649
Mailing address:
  • Phone: 781-391-5400
  • Fax: 781-396-0649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8266
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: