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General NPI Number Information
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NPI Number | 1164867479
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Entity Type | Organization
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Legal Business Name | DEROSA FACIAL PLASTIC SURGERY PC
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Dates
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Enumeration Date | 05/01/2013
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Last Update Date | 10/15/2014
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Provider Practice Location Address
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Address Line | 91 NEWBURY ST SUITE 300
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City | BOSTON
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State | MA
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Zip | 02116-3084
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Country | US
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Telephone | 617-262-8000
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Fax | 617-262-8002
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Provider Business Mailing Address
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Address Line | 91 NEWBURY ST SUITE 300
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City | BOSTON
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State | MA
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Zip | 02116-3084
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Country | US
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Telephone | 617-262-8000
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Fax | 617-262-8002
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAIMIE DEROSA
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Credential | MD
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Telephone | 617-262-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | 237016
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License Number State | MA
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