Healthcare Provider Details

I. General information

NPI: 1629185202
Provider Name (Legal Business Name): AMANDA S GROWDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE, MAIN S 9156 CHILDREN'S HOSPITAL BOSTON
BOSTON MA
02115
US

IV. Provider business mailing address

1 CHARLES ST S UNIT 2D
BOSTON MA
02116-5447
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-4993
  • Fax: 617-730-0884
Mailing address:
  • Phone: 617-355-4993
  • Fax: 617-730-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number227056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: