Healthcare Provider Details

I. General information

NPI: 1912326844
Provider Name (Legal Business Name): KATHERINE ROSE MARINO M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

119 BELMONT ST
WORCESTER MA
01605-2903
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-9530
  • Fax: 774-843-5498
Mailing address:
  • Phone: 508-334-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number274666
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: