Basic Information
| Provider Information | |||||||||
| NPI: | 1538232871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT AUBURN THERAPEUTIC ENDOSCOPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE ARSENAL MARKETPLACE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MOUNT AUBURN ST | ||||||||
| Address2: | STE 405 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176610221 | ||||||||
| FaxNumber: | 6176613862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUYMANN | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6176610221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 71422 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | M17551 | 01 | MA | BLUE CROSS GROUP | OTHER | 3052788 | 05 | MA | MEDICAID |