Healthcare Provider Details

I. General information

NPI: 1083633093
Provider Name (Legal Business Name): PEGGY ELLEN WARREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 WINDSOR ROAD
WABAN MA
02468
US

IV. Provider business mailing address

MASS GENERAL PHYSICIAN ORGANIZATION PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-964-3506
  • Fax: 617-964-9598
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number54564
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: