Healthcare Provider Details

I. General information

NPI: 1053394288
Provider Name (Legal Business Name): MICHAEL GANETSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEACONESS RD # WCC-2 BIDMC, DEPARTMENT OF EMERGENCY MEDICINE
BOSTON MA
02215-5321
US

IV. Provider business mailing address

1 DEACONESS RD WCC-2
BOSTON MA
02215-5321
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-2323
  • Fax: 617-754-2350
Mailing address:
  • Phone: 617-754-2323
  • Fax: 617-754-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number220259
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number220259
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: