Healthcare Provider Details

I. General information

NPI: 1003906637
Provider Name (Legal Business Name): KATHRYN J. SWOBODA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-5732
  • Fax: 617-724-9620
Mailing address:
  • Phone: 617-726-5732
  • Fax: 617-724-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number356086-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number152105
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number152105
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number152105
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number152105
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number152105
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: