Healthcare Provider Details

I. General information

NPI: 1912985037
Provider Name (Legal Business Name): ANDERS MARK KNUTZEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
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: 617-724-0288
  • Fax:
Mailing address:
  • Phone: 617-724-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34477
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number291560
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: