=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184039869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANELLA PAZ-LANSBERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2014
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 HARRISON AVE STE 400
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-638-8124
-----------------------------------------------------
Fax | 617-414-4953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 HARRISON AVE FL BCD5
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-638-7934
-----------------------------------------------------
Fax | 617-638-7965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 125065544
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 289543
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------