MEDICARE: BRYON A. GENTILE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0000X	Adolescent Medicine (Internal Medicine) Physician	250493	MA
2	207UN0901X	Nuclear Cardiology Physician	250493	MA
3	207RC0000X	Cardiovascular Disease Physician	250493	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821258179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYON A. GENTILE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 415348
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-5348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 LAKE AVE N
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01655-0002
Country	:	US
Telephone Number	:	508-334-3452
Fax Number	:	774-441-7657

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	11/04/2020

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