Provider Demographics
NPI:1053612788
Name:TACK, SAVATRI (NP)
Entity type:Individual
Prefix:MS
First Name:SAVATRI
Middle Name:
Last Name:TACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CENTRE STREET
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1000
Mailing Address - Country:US
Mailing Address - Phone:617-363-8010
Mailing Address - Fax:617-363-8929
Practice Address - Street 1:1200 CENTRE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1000
Practice Address - Country:US
Practice Address - Phone:617-363-8010
Practice Address - Fax:617-363-8929
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1974901OtherMEDICARE
MA110088213AMedicaid