Healthcare Provider Details

I. General information

NPI: 1124757737
Provider Name (Legal Business Name): EGOR SMIRNOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date: 03/20/2023
Reactivation Date: 08/09/2023

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-4398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1024926
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: