Basic Information
Provider Information | |||||||||
NPI: | 1700903499 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUVILLE HOSPITAL AND REHABILITATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1575 CAMBRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | CAMBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 021384308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6178764344 | ||||||||
FaxNumber: | 6172347900 | ||||||||
Practice Location | |||||||||
Address1: | 1575 CAMBRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | CAMBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 021384308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6178764344 | ||||||||
FaxNumber: | 6172347900 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KELLER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT CFO | ||||||||
AuthorizedOfficialTelephone: | 6178764344 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X |   |   | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 2222200004 | 01 | MA | BLUE CROSS MEDEX ONCOLOGY | OTHER |