Provider Demographics
NPI:1215909882
Name:FOGELMAN, AMY GOORIN (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:GOORIN
Last Name:FOGELMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:GOORIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:165 CAMBRIDGE ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2783
Mailing Address - Country:US
Mailing Address - Phone:617-726-4900
Mailing Address - Fax:617-228-6306
Practice Address - Street 1:165 CAMBRIDGE STREET
Practice Address - Street 2:SUITE 501
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2723
Practice Address - Country:US
Practice Address - Phone:617-726-4900
Practice Address - Fax:617-228-6306
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA39721Medicare PIN