Healthcare Provider Details

I. General information

NPI: 1730810987
Provider Name (Legal Business Name): BOSTON SPECIALISTS - SOUTH SHORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 KNEELAND ST FL 1
BOSTON MA
02111-1901
US

IV. Provider business mailing address

1 NASSAU ST UNIT 1906
BOSTON MA
02111-1587
US

V. Phone/Fax

Practice location:
  • Phone: 617-804-6767
  • Fax: 877-726-8492
Mailing address:
  • Phone: 617-804-6767
  • Fax: 877-726-8492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN LEUNG
Title or Position: OWNER
Credential: MD
Phone: 734-846-4910