Healthcare Provider Details

I. General information

NPI: 1548238967
Provider Name (Legal Business Name): PETER SIAO-TICK-CHONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY STREET, SUITE 7B SHAPIRO BLDG
BOSTON MA
02118-3549
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE, FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8456
  • Fax: 617-638-8465
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number60457
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number60457
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number60457
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: