Healthcare Provider Details

I. General information

NPI: 1891287207
Provider Name (Legal Business Name): ALEXANDRIA GINA GEORGADARELLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-335-5600
  • Fax:
Mailing address:
  • Phone: 617-335-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP04279
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number67568
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number1018463
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: