Healthcare Provider Details

I. General information

NPI: 1306284823
Provider Name (Legal Business Name): SUSAN HOGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN BOISVERT

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 11/08/2020
Certification Date: 11/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348 BOSTON
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-2818
  • Fax: 774-442-7799
Mailing address:
  • Phone: 800-225-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number268582
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: