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General NPI Number Information
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NPI Number | 1235180100
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Entity Type | Organization
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Legal Business Name | BEAVER BROOK PEDIATRIC & ADOLESCENT MEDICINE, P.C.
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 01/21/2020
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Provider Practice Location Address
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Address Line | 465 WAVERLEY OAKS RD SUITE 100
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City | WALTHAM
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State | MA
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Zip | 02452-8438
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Country | US
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Telephone | 781-891-3706
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Fax | 781-891-3564
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Provider Business Mailing Address
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Address Line | 465 WAVERLEY OAKS RD SUITE 100
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City | WALTHAM
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State | MA
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Zip | 02452-8438
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Country | US
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Telephone | 781-891-3706
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Fax | 781-891-3564
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | JANET L ANTONIONI
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Credential |
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Telephone | 781-891-3706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number |
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License Number State |
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