Provider Demographics
NPI:1124081625
Name:KASELIS, EDITH SANBORN (MD)
Entity type:Individual
Prefix:DR
First Name:EDITH
Middle Name:SANBORN
Last Name:KASELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 ROUTE 6A
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02675-1714
Mailing Address - Country:US
Mailing Address - Phone:508-833-0269
Mailing Address - Fax:508-833-1467
Practice Address - Street 1:179 ROUTE 6A
Practice Address - Street 2:
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675-1714
Practice Address - Country:US
Practice Address - Phone:508-833-0269
Practice Address - Fax:508-833-1467
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3106438Medicaid
MAJ13603OtherBLUE CROSS
MACIGNAOtherCIGNA
MA728557OtherTUFTS HEALTH PLAN
MA20844OtherHARVARD PILGRIM
MAF06079Medicare UPIN