Healthcare Provider Details

I. General information

NPI: 1629360680
Provider Name (Legal Business Name): CORNELIA LITTLE GRIGGS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST DEPT OF
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST WRN 1128 DEPARTMENT OF PEDIATRIC SURGERY
BOSTON MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2500
  • Fax:
Mailing address:
  • Phone: 617-724-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number260324
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: