=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336107309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA FRIBUSH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 03/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 ORNAC SUITE 570
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01742-4181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-371-7176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 EAST ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02420-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-371-7176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 74708
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------