Healthcare Provider Details

I. General information

NPI: 1669883245
Provider Name (Legal Business Name): JORDAN S SACK MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 08/20/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 FRANCIS ST ASB-II, GI CLINIC
BOSTON MA
02115-6110
US

IV. Provider business mailing address

45 FRANCIS ST ASB-II, GI CLINIC
BOSTON MA
02115-6110
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-6389
  • Fax: 617-566-0338
Mailing address:
  • Phone: 617-732-6389
  • Fax: 617-566-0338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number287611
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number287611
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number287611
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: