Provider Demographics
NPI:1992881288
Name:ST. VINCENT PSYCHIATRY ASSOCIATES
Entity type:Organization
Organization Name:ST. VINCENT PSYCHIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTSARIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-869-2699
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-869-2699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9733060Medicaid
MAM21478Medicare ID - Type Unspecified