=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154437549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLORIA KORTA, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 SWANTON ST SUITE 2
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01890-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-729-1930
-----------------------------------------------------
Fax | 781-729-1499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 SWANTON ST SUITE 2
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01890-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-729-1930
-----------------------------------------------------
Fax | 781-729-1499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GLORIA KORTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 781-729-1930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 55524
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------