Provider Demographics
NPI:1275193427
Name:MCGRATH, GANNON
Entity Type:Individual
Prefix:
First Name:GANNON
Middle Name:
Last Name:MCGRATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 PARKER HILL AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2855
Mailing Address - Country:US
Mailing Address - Phone:320-237-0038
Mailing Address - Fax:
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:651-789-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA280854208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery