Provider Demographics
NPI:1235129750
Name:CHAN, BERNADETTE (MD)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 GOVERNORS AVE
Mailing Address - Street 2:PROMPT CARE - LAWRENCE MEMORIAL HOSPITAL
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1643
Mailing Address - Country:US
Mailing Address - Phone:781-306-6103
Mailing Address - Fax:781-306-6206
Practice Address - Street 1:170 GOVERNORS AVE
Practice Address - Street 2:PROMPT CARE - LAWRENCE MEMORIAL HOSPITAL
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1643
Practice Address - Country:US
Practice Address - Phone:781-306-6103
Practice Address - Fax:781-306-6206
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60545207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200992Medicaid
MAJ10019Medicare ID - Type Unspecified
E56665Medicare UPIN