Healthcare Provider Details

I. General information

NPI: 1225546419
Provider Name (Legal Business Name): GERARD THONG MB, BCH, BAO, MCH,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF OTOLARYNGOLOGY, BOSTON CHILDRENS HOSPITAL 330 LONGWOOD AVENUE, BCH 3129
BOSTON MA
02115
US

IV. Provider business mailing address

11 HEREFORD ST UNIT B
BOSTON MA
02115-1602
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-5064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number273578
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: