Healthcare Provider Details

I. General information

NPI: 1083605984
Provider Name (Legal Business Name): JOHN PATRICK T CO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OCEAN AVENUE RCH REVERE HEALTHCARE CENTER
REVERE MA
02151-3675
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 781-485-6024
  • Fax: 781-485-6391
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number160256
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3201325
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierJ21625
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS MA
# 3
Identifier160256
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS HEALTH PLAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: