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General NPI Number Information
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NPI Number | 1376170522
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Entity Type | Individual
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Provider Name | JACK CHAN MD
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Gender | Male
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 10/15/2025
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Provider Practice Location Address
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Address Line | 101 SHATTUCK WAY STE 6
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City | NEWINGTON
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State | NH
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Zip | 03801-7876
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Country | US
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Telephone | 617-372-4018
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Fax |
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Provider Business Mailing Address
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Address Line | 101 SHATTUCK WAY STE 6
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City | NEWINGTON
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State | NH
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Zip | 03801-7876
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Country | US
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Telephone | 617-372-4018
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 34672
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License Number State | NH
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