Healthcare Provider Details

I. General information

NPI: 1972569143
Provider Name (Legal Business Name): CHARLES A HERGRUETER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST BWH - DIVISION OF PLASTIC AND RECONSTRUCTIVE SURGERY
BOSTON MA
02115-6110
US

IV. Provider business mailing address

111 CYPRESS ST
BROOKLINE MA
02445-6002
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-4550
  • Fax:
Mailing address:
  • Phone: 857-307-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number53230
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: