Healthcare Provider Details

I. General information

NPI: 1942543764
Provider Name (Legal Business Name): NEELAM M. THACKER, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST #210
MEDFORD MA
02155-4540
US

IV. Provider business mailing address

101 MAIN ST #210
MEDFORD MA
02155-4540
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-8100
  • Fax: 781-391-9929
Mailing address:
  • Phone: 781-396-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NEELAM M THACKER
Title or Position: M.D.
Credential: M.D.
Phone: 781-396-8100