Basic Information
| Provider Information | |||||||||
| NPI: | 1629026356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 WALL ST | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812212800 | ||||||||
| FaxNumber: | 7812212680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 05/16/2011 | ||||||||
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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 | 207R00000X | 52950 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | V303 | 01 | MA | HARVARD PILGRIM | OTHER | 0015268 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 3014347 | 05 | MA | MEDICAID | 052950 | 01 | MA | TUFTS | OTHER | J06157 | 01 | MA | BLUE CROSS | OTHER |