Healthcare Provider Details

I. General information

NPI: 1104265834
Provider Name (Legal Business Name): CHARLES DONALD HANNUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2013
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST # 286 FLOATING HOSPITAL FOR CHILDREN, TUFTS MEDICAL CENTER
BOSTON MA
02111-1552
US

IV. Provider business mailing address

474 MASSACHUSETTS AVE APT 3
BOSTON MA
02118-1139
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5078
  • Fax:
Mailing address:
  • Phone: 617-433-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number255812
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: