Healthcare Provider Details

I. General information

NPI: 1033374731
Provider Name (Legal Business Name): WAYLAND PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 PELHAM ISLAND RD
WAYLAND MA
01778-2625
US

IV. Provider business mailing address

73 PELHAM ISLAND RD
WAYLAND MA
01778-2625
US

V. Phone/Fax

Practice location:
  • Phone: 508-358-6054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number72178
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SALLIE MADY
Title or Position: PHYSICIAN
Credential: MD
Phone: 508-358-2918