Healthcare Provider Details

I. General information

NPI: 1760680987
Provider Name (Legal Business Name): SOUTH SUBURBAN PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ADAMS STREET
QUINCY MA
02169
US

IV. Provider business mailing address

101 ADAMS STREET
QUINCY MA
02169
US

V. Phone/Fax

Practice location:
  • Phone: 617-773-7754
  • Fax: 617-328-0957
Mailing address:
  • Phone: 617-773-7754
  • Fax: 617-328-0957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54474
License Number StateMA

VIII. Authorized Official

Name: DR. GEORGE HOM
Title or Position: PRESIDENT
Credential: MD
Phone: 617-773-7754