Organization
DEROSA FACIAL PLASTIC SURGERY PC
Active
Other names
DeRosa Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAIMIE DEROSA MD (PRESIDENT)
(617) 262-8000
Entity
Organization
Contact information
Practice address
91 NEWBURY ST, SUITE 300, BOSTON, MA 02116-3084
(617) 262-8000
(617) 262-8002
Mailing address
91 NEWBURY ST, SUITE 300, BOSTON, MA 02116-3084
(617) 262-8000
(617) 262-8002
Taxonomy
Speciality
Code
Description
License number
State
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
Primary
237016
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000755302
MEDICARE PROVIDER PTAN
—
01
—
0032529
MEDICARE GROUP PTAN
—
Enumeration date
05/01/2013
Last updated
10/15/2014
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