Healthcare Provider Details

I. General information

NPI: 1982600144
Provider Name (Legal Business Name): ANDREW T CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST GRJ-722
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3212
  • Fax: 617-724-6832
Mailing address:
  • Phone: 617-726-3212
  • Fax: 617-724-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number210410
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: