Provider Demographics
NPI:1215925888
Name:GEORGE H. THEODORE, MD PC
Entity type:Organization
Organization Name:GEORGE H. THEODORE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-726-1344
Mailing Address - Street 1:175 CAMBRIDGE ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2743
Mailing Address - Country:US
Mailing Address - Phone:617-724-7009
Mailing Address - Fax:617-643-1006
Practice Address - Street 1:175 CAMBRIDGE ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2743
Practice Address - Country:US
Practice Address - Phone:617-724-7009
Practice Address - Fax:617-643-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150940207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA727867OtherTUFTS
MA9730290Medicaid
MAM18225OtherBCBS MA
MA173652OtherHPHC
MAM18225OtherBCBS MA
MA9730290Medicaid