Healthcare Provider Details

I. General information

NPI: 1881660322
Provider Name (Legal Business Name): SHAHRAM KHOSHBIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE CHILDREN'S UROLOGY FOUNDATION
BOSTON MA
02115
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-5081
  • Fax:
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number42900
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number42900
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: