Provider Demographics
NPI:1386608974
Name:MACKIEWICZ, HENRY T
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:T
Last Name:MACKIEWICZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 325
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2620
Mailing Address - Country:US
Mailing Address - Phone:617-414-4505
Mailing Address - Fax:781-407-0998
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-789-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216399207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2012821Medicaid
MAA35099Medicare ID - Type Unspecified
MAH80212Medicare UPIN