=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740740430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA DARBY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2019
-----------------------------------------------------
Last Update Date | 06/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 HARRISON AVE RADIOLOGY - BOSTON MEDICAL CENTER
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-638-6610
-----------------------------------------------------
Fax | 617-638-6616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 HARRISON AVENUE ENROLLMENT OFFICE DOB 503
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02118-2371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-414-5405
-----------------------------------------------------
Fax | 617-414-6031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA6994
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------