MEDICARE: ANTHONY VANNIEL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	47553	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J02423	OTHER	MA	BLUE CROSS

General Provider Information

NPI Number	:	1740255660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY VANNIEL MD

Provider Business Mailing Address
First Line	:	875 MASSACHUSETTS AVE
Second Line	:	SUITE 51
City	:	CAMBRIDGE
State	:	MA
Zip	:	02139-3067
Country	:	US
Telephone Number	:	617-864-8482
Fax Number	:

Provider Business Practice Location Address
First Line	:	875 MASSACHUSETTS AVE
Second Line	:	SUITE 51
City	:	CAMBRIDGE
State	:	MA
Zip	:	02139-3067
Country	:	US
Telephone Number	:	617-864-8482
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	09/02/2011

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