Basic Information
| Provider Information | |||||||||
| NPI: | 1720240047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 LAKE AVE N | ||||||||
| Address2: | PEDIATRIC PULMONOLOGY | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016550002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088564155 | ||||||||
| FaxNumber: | 5088562609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 247765 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0214X | 247765 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 110093403A | 05 | MA | MEDICAID | S400154811 | 01 | MA | MEDICARE | OTHER |