Provider Demographics
NPI:1942543764
Name:NEELAM M. THACKER, M.D.
Entity Type:Organization
Organization Name:NEELAM M. THACKER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:NEELAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-396-8100
Mailing Address - Street 1:101 MAIN ST
Mailing Address - Street 2:#210
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4540
Mailing Address - Country:US
Mailing Address - Phone:781-396-8100
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:#210
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4540
Practice Address - Country:US
Practice Address - Phone:781-396-8100
Practice Address - Fax:781-391-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1790832822OtherTYPE 1 NPI #