Basic Information
| Provider Information | |||||||||
| NPI: | 1134184161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BADER | ||||||||
| FirstName: | WALID | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019152734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 HERRICK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019152734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789274110 | ||||||||
| FaxNumber: | 9782327057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1117 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 224414 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2113601 | 05 | MA | MEDICAID | 011178 | 05 | SC | MEDICAID | WB58304 | 01 | RI | MEDICAID | OTHER |