Basic Information
| Provider Information | |||||||||
| NPI: | 1508352048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | BRIGHAM & WOMEN'S HOSPITAL, VASCULAR AND ENDOVASCULAR S | ||||||||
| Address2: | 75 FRANCIS ST. | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573071920 | ||||||||
| FaxNumber: | 8573071922 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CAPITAL WAY STE 356 | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095376000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2018 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/13/2019 | ||||||||
| NPIReactivationDate: | 03/20/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0129X | 25MA10923300 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.