Basic Information
| Provider Information | |||||||||
| NPI: | 1528109816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JBG, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 WALNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024601689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
| FaxNumber: | 6172441827 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MILL ST | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024764784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816410107 | ||||||||
| FaxNumber: | 7816411020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | GIMBEL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | BARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7816410107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | 1394 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Podiatric |
ID Information
| ID | Type | State | Issuer | Description | 480015323 | 01 | MA | PALMETTO GBA - GROUP | OTHER | 656084 | 01 | MA | TUFTS - GROUP | OTHER | 9738941 | 05 | MA | MEDICAID | Y77350 | 01 | MA | BCBSMA - GROUP | OTHER |