Healthcare Provider Details

I. General information

NPI: 1609884519
Provider Name (Legal Business Name): IAN JAMES THORNLEY MB BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 HIGHLAND AVE NORTH SHORE CHILDRENS HOSPITAL PEDIATRIC EMERGENCY ROOM
SALEM MA
01970
US

IV. Provider business mailing address

27 CAMDEN ROAD
AUBURNDALE MA
02466
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-2750
  • Fax:
Mailing address:
  • Phone: 617-244-5248
  • Fax: 617-244-5248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number215122
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: