Healthcare Provider Details

I. General information

NPI: 1487628087
Provider Name (Legal Business Name): VIRGINIA FITZGERALD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W BROADWAY
SOUTH BOSTON MA
02127-2245
US

IV. Provider business mailing address

409 W BROADWAY
SOUTH BOSTON MA
02127-2245
US

V. Phone/Fax

Practice location:
  • Phone: 617-269-7500
  • Fax: 617-464-7512
Mailing address:
  • Phone: 617-269-7500
  • Fax: 617-464-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54611
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: