Healthcare Provider Details

I. General information

NPI: 1760057319
Provider Name (Legal Business Name): WEST SUBURBAN GI PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

IV. Provider business mailing address

28 NEWTON ST
SOUTHBOROUGH MA
01772-1215
US

V. Phone/Fax

Practice location:
  • Phone: 508-281-0600
  • Fax:
Mailing address:
  • Phone: 508-281-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL O'SULLIVAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 603-496-2895