=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508927922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLESEX CARDIOLOGY ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 ROWE ST SUITE 600
-----------------------------------------------------
City | MELROSE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-979-3440
-----------------------------------------------------
Fax | 781-979-0258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 ROWE ST SUITE 600
-----------------------------------------------------
City | MELROSE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-979-3440
-----------------------------------------------------
Fax | 781-979-0258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SUSAN WAYSTACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-979-3440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------