Provider Demographics
NPI:1073795639
Name:SHANTANU BASU MD PC
Entity Type:Organization
Organization Name:SHANTANU BASU MD PC
Other - Org Name:SHANTANU BASU MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTANU
Authorized Official - Middle Name:G
Authorized Official - Last Name:BASU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-277-5587
Mailing Address - Street 1:125 PARKER HILL AVE
Mailing Address - Street 2:SUITE 385
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:617-277-5587
Mailing Address - Fax:617-232-1660
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:SUITE 385
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-277-5587
Practice Address - Fax:617-232-1660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANTANU BASU MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0129127Medicaid