Healthcare Provider Details

I. General information

NPI: 1366427429
Provider Name (Legal Business Name): EVAN PAUL PROVISOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 SOUTH ST
SOUTHBRIDGE MA
01550-4000
US

IV. Provider business mailing address

94 SOUTH ST
SOUTHBRIDGE MA
01550-4000
US

V. Phone/Fax

Practice location:
  • Phone: 508-764-6966
  • Fax: 508-764-2457
Mailing address:
  • Phone: 508-764-6966
  • Fax: 508-764-2457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number237945
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: