Basic Information
| Provider Information | |||||||||
| NPI: | 1437240199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | ROSEMARIE | ||||||||
| MiddleName: | ROQUE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE BOSTON MEDICAL CENTER PLACE | ||||||||
| Address2: | DIVISION OF PEDIATRICS DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | 6174143803 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE BOSTON MEDICAL CENTER PLACE | ||||||||
| Address2: | CHILD HEALTH FOUNDATION OF BOSTON DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | 6174143803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 226695 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2119285 | 05 | MA | MEDICAID |