Provider Demographics
NPI:1063560530
Name:HOM, GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:HOM
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 1:101 ADAMS STREET
Mailing Address - Street 2:SUITE 20
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-7754
Mailing Address - Fax:617-328-0957
Practice Address - Street 1:101 ADAMS STREET
Practice Address - Street 2:SUITE 20
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-7754
Practice Address - Fax:617-328-0957
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54474208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2267596OtherAETNA
MA000000008498OtherBOSTON HEALTH NET
MA054474OtherTUFTS
MA202111OtherHARVARD
MA3009742Medicaid
MAB10391101OtherCIGNA
MAJ05656OtherBCBS
MA1201532OtherUNITED
E98015Medicare UPIN
MAJO5656Medicare ID - Type Unspecified