Provider Demographics
NPI:1316020712
Name:CORRADO, GIANMICHEL D (MD)
Entity Type:Individual
Prefix:
First Name:GIANMICHEL
Middle Name:D
Last Name:CORRADO
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 1:319 LONGWOOD AVE
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5728
Mailing Address - Country:US
Mailing Address - Phone:617-355-6028
Mailing Address - Fax:617-731-5298
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-355-6028
Practice Address - Fax:617-731-5298
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212795207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0196479Medicaid
MA0196479Medicaid
A34003Medicare PIN
VX2300Medicare PIN