Healthcare Provider Details

I. General information

NPI: 1942420476
Provider Name (Legal Business Name): HEMALUCK SUWATANAPONGCHED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE YACC 5
BOSTON MA
02118-4001
US

IV. Provider business mailing address

PO BOX 400772
CAMBRIDGE MA
02140-0008
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number237876
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: