Healthcare Provider Details

I. General information

NPI: 1790165546
Provider Name (Legal Business Name): EDWARD BAHNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HERRICK ST STE 101
BEVERLY MA
01915-2734
US

IV. Provider business mailing address

77 HERRICK ST STE 101
BEVERLY MA
01915-2734
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-4110
  • Fax:
Mailing address:
  • Phone: 978-927-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116027984
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number277197
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: