Healthcare Provider Details

I. General information

NPI: 1184074098
Provider Name (Legal Business Name): TYLER BRENDAN DRAEGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

75 FRANCIS ST DIVISION OF THORACIC SURGERY
BOSTON MA
02115-6106
US

V. Phone/Fax

Practice location:
  • Phone: 401-736-1092
  • Fax: 401-738-0013
Mailing address:
  • Phone: 617-525-6757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA160740
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number292835
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD19384
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: