Healthcare Provider Details

I. General information

NPI: 1750807772
Provider Name (Legal Business Name): ALEXANDER G. KOCULYM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST MASSACHUSETTS GENERAL HOSPITAL
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST MASSACHUSETTS GENERAL HOSPITAL
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-2009
  • Fax:
Mailing address:
  • Phone: 617-643-2009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number270458
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: