Healthcare Provider Details

I. General information

NPI: 1962669861
Provider Name (Legal Business Name): BETH M AMUNDSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST SUITE
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST STE. 517
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-4533
  • Fax:
Mailing address:
  • Phone: 617-643-4533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: