Basic Information
| Provider Information | |||||||||
| NPI: | 1942313531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEHLAU | ||||||||
| FirstName: | IRMGARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 SOLDIERS FIELD ROAD 2ND FLOOR MAGGIE CUSTODIO | ||||||||
| Address2: | MOUNT AUBURN CAMBRIDGE INDEPENDENT PRACTICE ASSOCIATION | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174995026 | ||||||||
| FaxNumber: | 6174995453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 SOLDIERS FIELD ROAD, 2ND FLOOR MAGGIE CUSTODIO | ||||||||
| Address2: | MOUNT AUBURN CAMBRIDGE INDEPENDENT PRACTICE ASSOCIATION | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177837200 | ||||||||
| FaxNumber: | 6177871760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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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 | 75971 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 75971 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | J19423 | 01 | MA | BCBS MA | OTHER | 792606 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 3185834 | 05 | MA | MEDICAID |