Healthcare Provider Details

I. General information

NPI: 1710728050
Provider Name (Legal Business Name): PETER GALIWANGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 STATION LNDG APT 431W
MEDFORD MA
02155-5031
US

IV. Provider business mailing address

1094 WORCESTER RD
FRAMINGHAM MA
01702-5255
US

V. Phone/Fax

Practice location:
  • Phone: 978-489-8380
  • Fax:
Mailing address:
  • Phone: 508-661-2020
  • Fax: 508-661-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN2378862
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberRN2378862
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: