Healthcare Provider Details

I. General information

NPI: 1861627796
Provider Name (Legal Business Name): SANJAY P PRABHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVENUE CHILDREN'S HOSPITAL BOSTON/RADIOLOGY
BOSTON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVENUE CHILDREN'S HOSPITAL BOSTON/RADIOLOGY
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6936
  • Fax: 617-730-0549
Mailing address:
  • Phone: 617-355-6936
  • Fax: 617-730-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number239721
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number239721
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: