Provider Demographics
NPI:1396703542
Name:SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC
Entity type:Organization
Organization Name:SOUTHERN NEW ENGLAND RETINA ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGDALENA
Authorized Official - Middle Name:G
Authorized Official - Last Name:KRZYSTOLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-695-9550
Mailing Address - Street 1:30 MAN MAR DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PLAINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02762-2271
Mailing Address - Country:US
Mailing Address - Phone:508-695-9550
Mailing Address - Fax:508-695-9505
Practice Address - Street 1:30 MANMAR DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PLAINVILLE
Practice Address - State:MA
Practice Address - Zip Code:02703-2271
Practice Address - Country:US
Practice Address - Phone:508-695-9550
Practice Address - Fax:508-695-9505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN NEW ENGLAND RETINA ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-03
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA624129OtherTUFTS
RI9004676Medicaid
MA7246790OtherAETNA
MA9762591Medicaid
MAM19151OtherBCBS
MA=========OtherCIGNA
MA7246790OtherAETNA
MAM19151OtherBCBS