Individual
SAM NIA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
55 LAKE AVE N, WORCESTER, MA 01655-0002
(508) 334-3271
(508) 856-5911
Mailing address
353 MARLBOROUGH ST APT 4, BOSTON, MA 02115-1717
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
272485
MA
207LP2900X
Pain Medicine (Anesthesiology) Physician
272485
MA
207LP3000X
Pediatric Anesthesiology Physician
272485
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110126580A
—
MA
Enumeration date
03/08/2012
Last updated
05/20/2021
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