Healthcare Provider Details

I. General information

NPI: 1467440735
Provider Name (Legal Business Name): MATTHEW PETER ANDERSON M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE DEPT. OF NEUROLOGY
BOSTON MA
02215-5400
US

IV. Provider business mailing address

77 AVENUE LOUIS PASTEUR HIM 846
BOSTON MA
02115-5727
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3090
  • Fax:
Mailing address:
  • Phone: 617-667-0853
  • Fax: 617-667-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number153393
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: