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Provider Information for 1972538379

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: 1972538379

Calendar   Last Updated:  2022-02-23
  Certification Date:  2022-02-23


Name Value
NPI 1972538379
Enumeration Date 2006-07-12
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 45 TEMPLE ST UNIT 510
BOSTON, MA 02114-4273
United States

Phone: 617-840-1941 | Fax:
View Map External Link
Primary Practice Address 300 LONGWOOD AVE FEGAN 3
BOSTON, MA 02115-5724
United States

Phone: 617-355-9600 | Fax: 617-730-0477
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 2086S0120X - Surgery Pediatric Surgery MA 51940
No 208600000X - Surgery MA 51940
No 2086S0102X - Surgery Surgical Critical Care MA 51940