Basic Information
| Provider Information | |||||||||
| NPI: | 1366731291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER BOSTON GASTROENTEROLGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 FRANKLIN ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017026264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086209200 | ||||||||
| FaxNumber: | 5086206483 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 FRANKLIN ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017026264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086209200 | ||||||||
| FaxNumber: | 5086206483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5086209200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 637393 | 01 | MA | TUFTS | OTHER | DB5286 | 01 | MA | RR MEDICARE | OTHER | M21436 | 01 | MA | MEDICARE / PTAN | OTHER | 9738487 | 05 | MA | MEDICAID | 92401 | 01 | MA | FALLON | OTHER | M17578 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 3663248 | 01 | MA | CIGNA | OTHER |