Healthcare Provider Details

I. General information

NPI: 1912407768
Provider Name (Legal Business Name): DR. JACKIE J LIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEACONESS ROAD RADIOLOGY DEPT., BIDMC
BOSTON MA
02215
US

IV. Provider business mailing address

310 TWEEDSMUIR AVENUE UNIT 320
TORONTO ONTARIO
522
CA

V. Phone/Fax

Practice location:
  • Phone: 617-754-2519
  • Fax: 617-754-2545
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number66597
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: