Provider Demographics
NPI:1164649315
Name:SP GANGULY MD PC
Entity Type:Organization
Organization Name:SP GANGULY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SYAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGULY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-238-8646
Mailing Address - Street 1:944 WASHINGTON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1177
Mailing Address - Country:US
Mailing Address - Phone:508-238-8646
Mailing Address - Fax:508-230-9772
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-340-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32940208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9734341Medicaid
MAM21884OtherBLUE SHIELD
MAM21884OtherBLUE SHIELD