Basic Information
| Provider Information | |||||||||
| NPI: | 1144240789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD,FACC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 HERRICK ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019155900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789278400 | ||||||||
| FaxNumber: | 9789221452 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 HERRICK ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019155900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789278400 | ||||||||
| FaxNumber: | 9789221452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 59741 | MA | N | Other Service Providers | Specialist | 207RC0000X | 59741 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060058690 | 01 | MA | RAILROAD MEDICARE | OTHER | 4231092 | 01 | MA | AETNA | OTHER | 2500717 | 01 | MA | UNITED HEALTHCARE | OTHER | J07711 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 3053024 | 05 | MA | MEDICAID | 042804155 | 01 | MA | CIGNA | OTHER | 60917 | 01 | MA | HARVARD PILGRIM | OTHER | 97126301 | 01 | MA | NETWORK HEALTH PLAN | OTHER | 0016080 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 059741 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 32041 | 01 | MA | FALLON COMMUNITY HEALTH | OTHER |