Healthcare Provider Details

I. General information

NPI: 1205817913
Provider Name (Legal Business Name): PAUL R TANGUAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N PEARL ST ATTN PATHOLOGY DEPT
BROCKTON MA
02301-1794
US

IV. Provider business mailing address

235 NORTH PEARL ST DEPT OF PATHOLOGY
BROCKTON MA
02301-1794
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-3086
  • Fax: 508-588-0520
Mailing address:
  • Phone: 508-427-3086
  • Fax: 508-588-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number40290
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number40290
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number40290
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: