Healthcare Provider Details

I. General information

NPI: 1609291376
Provider Name (Legal Business Name): MT AUBURN PROFESSIONAL OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE ARSENAL MARKETPLACE
WATERTOWN MA
02472-2861
US

IV. Provider business mailing address

ONE ARSENAL MARKETPLACE
WATERTOWN MA
02472-2861
US

V. Phone/Fax

Practice location:
  • Phone: 617-499-5644
  • Fax: 617-499-5620
Mailing address:
  • Phone: 617-499-5644
  • Fax: 617-499-5620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. BRIAN SMITH
Title or Position: CFO
Credential:
Phone: 405-245-6238