Healthcare Provider Details

I. General information

NPI: 1962186049
Provider Name (Legal Business Name): BEACON PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LONGWATER DR FL 2
NORWELL MA
02061-1639
US

IV. Provider business mailing address

600 LONGWATER DR FL 2
NORWELL MA
02061-1639
US

V. Phone/Fax

Practice location:
  • Phone: 781-745-3322
  • Fax:
Mailing address:
  • Phone: 781-745-3322
  • Fax: 781-561-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GINA S BOUTWELL
Title or Position: PRESIDENT
Credential: MD
Phone: 781-745-3322