Healthcare Provider Details

I. General information

NPI: 1891938528
Provider Name (Legal Business Name): AMY WISTERIA BAUGHMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 09/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT STREET VETERANS AFFAIRS BOSTON HEALTHCARE SYSTEM
BROCKTON MA
02301
US

IV. Provider business mailing address

940 BELMONT STREET GERIATRICS & EXTENDED CARE
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-1860
  • Fax:
Mailing address:
  • Phone: 774-826-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number252442
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number252442
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: