Basic Information
| Provider Information | |||||||||
| NPI: | 1396726592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZANCA | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C O MSI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 WASHINGTON STRRET | ||||||||
| Address2: | ATTN EMERGENCY DEPT | ||||||||
| City: | TANNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088287108 | ||||||||
| FaxNumber: | 5088287158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 57959 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 057959 | 01 | MA | TUFTS | OTHER | 3021076 | 05 | MA | MEDICAID | J06421 | 01 | MA | BCBS | OTHER | 436523 | 01 | MA | HPHC | OTHER |