Basic Information
| Provider Information | |||||||||
| NPI: | 1639153547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | ILAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BOSTON MEDICAL CENTER PL | ||||||||
| Address2: | DIVISION OF PEDIATRICS, DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | 6174143803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BOSTON MEDICAL CENTER PL | ||||||||
| Address2: | CHILD HEALTH FOUNDATION OF BOSTON , DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | 6174143803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 153746 | MA | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 153746 | MA | X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3168158 | 05 | MA | MEDICAID |