Provider Demographics
NPI:1487095295
Name:BREEN, MICHEAL ANTHONY (MB BCH BAO)
Entity type:Individual
Prefix:DR
First Name:MICHEAL
Middle Name:ANTHONY
Last Name:BREEN
Suffix:
Gender:M
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6936
Mailing Address - Fax:617-730-0549
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6936
Practice Address - Fax:617-730-0549
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2665342085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200445Medicaid