=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801834023
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT S NIERMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 MT. AUBORN STREET TUFTS HEALTH PLAN
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-972-9025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 VALLEYFIELD ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02421-7949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-972-9025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 38289
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------