Healthcare Provider Details

I. General information

NPI: 1366112153
Provider Name (Legal Business Name): MARTIN EGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 WASHINGTON ST STE P55
NORWELL MA
02061-1742
US

IV. Provider business mailing address

118 N BEDFORD ST
EAST BRIDGEWATER MA
02333-3500
US

V. Phone/Fax

Practice location:
  • Phone: 781-290-3886
  • Fax:
Mailing address:
  • Phone: 508-840-7945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: