Healthcare Provider Details

I. General information

NPI: 1124081625
Provider Name (Legal Business Name): EDITH SANBORN KASELIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 ROUTE 6A
YARMOUTH PORT MA
02675-1714
US

IV. Provider business mailing address

179 ROUTE 6A
YARMOUTH PORT MA
02675-1714
US

V. Phone/Fax

Practice location:
  • Phone: 508-833-0269
  • Fax: 508-833-1467
Mailing address:
  • Phone: 508-833-0269
  • Fax: 508-833-1467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number75612
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: