Basic Information
| Provider Information | |||||||||
| NPI: | 1497866339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALLY | ||||||||
| FirstName: | KATE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176326464 | ||||||||
| FaxNumber: | 6176326180 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176326464 | ||||||||
| FaxNumber: | 6176326180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD425183 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | MD13953 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RH0002X | 275932 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2406111000 | 01 | INDEPENDENCE BLUE CROSS | OTHER | LA1739656 | 01 | PA | HIGHMARK BS | OTHER |