Basic Information
| Provider Information | |||||||||
| NPI: | 1306874169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | WAIFONG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAN | ||||||||
| OtherFirstName: | WAI FONG | ||||||||
| OtherMiddleName: | ANNIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 55 FRUIT STREET | ||||||||
| Address2: | COX 337 MASSACHUSETTS GENERAL HOSPITAL | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177241159 | ||||||||
| FaxNumber: | 6177263603 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BLOSSOMS STREET | ||||||||
| Address2: | COX LL MASSACHUSETTS GENERAL HOSPITAL, | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177241159 | ||||||||
| FaxNumber: | 6177263603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 205315 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 205315 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0117170 | 05 | MA | MEDICAID | J22411 | 01 | MA | BCBS MA | OTHER |