Healthcare Provider Details

I. General information

NPI: 1942378633
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF MALDEN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COMMERCIAL ST
MALDEN MA
02148-5509
US

IV. Provider business mailing address

105 COMMERCIAL ST
MALDEN MA
02148-5509
US

V. Phone/Fax

Practice location:
  • Phone: 781-322-5101
  • Fax: 781-322-5820
Mailing address:
  • Phone: 781-322-5101
  • Fax: 781-322-5820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierM17324
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS
# 2
Identifier683054
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFFY HEALTH PLAN
# 3
Identifier9785973
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: TIEN LAN CHANG
Title or Position: PRESIDENT
Credential: MD
Phone: 781-322-5101