Healthcare Provider Details

I. General information

NPI: 1831171297
Provider Name (Legal Business Name): ROBERT LEO SHERIDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 BLOSSOM STREET SBI SHRINERS BURN INSTITUTE
BOSTON MA
02114
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 617-726-5633
  • Fax: 617-367-8936
Mailing address:
  • Phone: 617-726-5633
  • Fax: 617-371-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number74746
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number74746
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: