Healthcare Provider Details

I. General information

NPI: 1295787562
Provider Name (Legal Business Name): KAREN JEAN BACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 PELHAM ISLAND ROAD
WAYLAND MA
01778
US

IV. Provider business mailing address

73 PELHAM ISLAND ROAD
WAYLAND MA
01778
US

V. Phone/Fax

Practice location:
  • Phone: 508-358-2918
  • Fax: 508-358-6054
Mailing address:
  • Phone: 508-358-2918
  • Fax: 508-358-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43580
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: