Provider Demographics
NPI:1124088844
Name:CLANCY, JANE E (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:CLANCY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6000
Practice Address - Fax:617-972-5100
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA482192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04214OtherBLUE CROSS
MA3014118Medicaid
MAB21211801OtherHEALTHSOURCE
MAR209OtherHARVARD PILGRIM
MA0000849OtherNEIGHBORHOOD HEALTH
MA1971454-001OtherCIGNA
MA702782OtherTUFTS
MAFX6258Medicare PIN
MA702782OtherTUFTS