MEDICARE: MS. DIANE GRIFFITHS PECK CNM

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	367A00000X	Advanced Practice Midwife	NM172899	MA

General Provider Information

NPI Number	:	1760483002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE GRIFFITHS PECK CNM

Provider Business Mailing Address
First Line	:	415 COLUMBIA ROAD
Second Line	:	UPHAMS CORNER HEALTH CENTER
City	:	BOSTON
State	:	MA
Zip	:	02125
Country	:	US
Telephone Number	:	617-740-8000
Fax Number	:	617-740-8060

Provider Business Practice Location Address
First Line	:	415 COLUMBIA ROAD
Second Line	:	UPHAMS CORNER HEALTH CENTER
City	:	BOSTON
State	:	MA
Zip	:	02125
Country	:	US
Telephone Number	:	617-740-8000
Fax Number	:	617-740-8060

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/30/2007

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