Healthcare Provider Details

I. General information

NPI: 1124088844
Provider Name (Legal Business Name): JANE E CLANCY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

147 MILK ST 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6000
  • Fax: 617-972-5100
Mailing address:
  • Phone: 617-421-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number48219
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: