=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710728050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER GALIWANGO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 STATION LNDG APT 431W
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-489-8380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1094 WORCESTER RD
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01702-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-661-2020
-----------------------------------------------------
Fax | 508-661-2024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0807X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | RN2378862
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | RN2378862
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------