1396706503 NPI number — JOHN KORETH MBBS DPHIL

Table of content: JOHN KORETH MBBS DPHIL (NPI 1396706503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396706503 NPI number — JOHN KORETH MBBS DPHIL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORETH
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MBBS DPHIL
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396706503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 BINNEY ST
Provider Second Line Business Mailing Address:
D1B 22
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02115-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-632-2949
Provider Business Mailing Address Fax Number:
617-632-5168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 BINNEY ST
Provider Second Line Business Practice Location Address:
D1B 22
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02115-6013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-632-2949
Provider Business Practice Location Address Fax Number:
617-632-5168
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  208706 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 208706 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3616024 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3600442 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3634386 . This is a "AETNA US HEALTCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J27417 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2042941 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9348554 . This is a "PRIVATE HEALTH CARE SYS" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA13671 . This is a "HPHC DFCI ONLY" identifier . This identifiers is of the category "OTHER".




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