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Provider Information for 1376818591

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1376818591

Calendar   Last Updated:  2017-01-10
  Certification Date: 


Name Value
NPI 1376818591
Enumeration Date 2012-03-21
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 141 SOUTH ST
BOSTON, MA 02130-3823
United States

Phone: 608-695-5787 | Fax:
View Map External Link
Primary Practice Address 300 LONGWOOD AVE
BOSTON, MA 02115-5724
United States

Phone: 617-355-6000 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 208000000X - Pediatrics MA 262430
No 2080P0204X - Pediatrics Pediatric Emergency Medicine MA 262430