Healthcare Provider Details

I. General information

NPI: 1871911511
Provider Name (Legal Business Name): CYNTHIA M POULOS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SOUTH STREET
NORTHBOROUGH MA
01532
US

IV. Provider business mailing address

17 SOUTH STREET
NORTHBOROUGH MA
01532
US

V. Phone/Fax

Practice location:
  • Phone: 508-393-4544
  • Fax:
Mailing address:
  • Phone: 508-393-4544
  • Fax: 508-393-4692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number78672
License Number StateMA

VIII. Authorized Official

Name: CYNTHIA M POULOS
Title or Position: OWNER/PROVIDER
Credential: MD LLC
Phone: 508-393-4544