=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497776728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEDRO R. POLITZER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 291 INDEPENDENCE DR
-----------------------------------------------------
City | CHESTNUT HILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02467-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-541-6575
-----------------------------------------------------
Fax | 617-541-7510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 147 MILK ST PROVIDER ENROLLMENT 9TH FLOOR
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02109-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-559-8051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 43905
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------