Provider Demographics
NPI:1982600144
Name:CHAN, ANDREW T (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:T
Last Name:CHAN
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 1:55 FRUIT ST
Mailing Address - Street 2:GRJ-722
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-3212
Mailing Address - Fax:617-724-6832
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-3212
Practice Address - Fax:617-724-6832
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210410207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHH40331OtherANTHEM BLUE CROSS
NH30205076OtherNH MEDICAID
MA210410OtherTUFTS HEALTH PLAN
MAAA13929OtherHARVARD PILGRIM HEALTHCAR
MA0024168OtherNEIGHBORHOOD HEALTH PLAN
MA6831017OtherHEALTHSOURCE
MAJ23432OtherBLUE CROSS BLUE SHIELD
MA0134031Medicaid
6584416OtherCIGNA
MA994677OtherNETWORK HEALTH
MA0134031Medicaid
MAJ23432OtherBLUE CROSS BLUE SHIELD