Healthcare Provider Details

I. General information

NPI: 1609579630
Provider Name (Legal Business Name): GREGORY MICHAEL GHEEWALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 09/16/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE, BOSTON MEDICAL CENTER 6TH FLOOR
BOSTON MA
02118
US

IV. Provider business mailing address

801 MASSACHUSETTS AVE SUITE 6C CROSSTOWN BLDG
BOSTON MA
02118-2605
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5951
  • Fax: 617-414-9201
Mailing address:
  • Phone: 617-414-5951
  • Fax: 617-414-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1027268
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: