Provider Demographics
NPI:1114218146
Name:FAWLEY, JASON ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANDREW
Last Name:FAWLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CAMBRIDGE ST STE 810
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN STREET
Practice Address - Street 2:CHURCHILL SURGICAL CLINIC
Practice Address - City:BOST
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-643-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2804672086S0102X, 208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114218146Medicaid