Provider Demographics
NPI:1235265943
Name:FRACCHIA, MARY SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SHANNON
Last Name:FRACCHIA
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:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - Street 2:55 FRUIT STREET
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-724-8707
Mailing Address - Fax:
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:55 FRUIT STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-2243262080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110079138/AMedicaid
MA110079138/AMedicaid