1053386771 NPI number — IDA P GORENBURG M.D.

Table of content: IDA P GORENBURG M.D. (NPI 1053386771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053386771 NPI number — IDA P GORENBURG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORENBURG
Provider First Name:
IDA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1053386771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 MILK ST
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT - 9TH FLOOR
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02109-4806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-559-8374
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 WORCESTER ST
Provider Second Line Business Practice Location Address:
INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02481-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-431-5220
Provider Business Practice Location Address Fax Number:
781-431-5526
Provider Enumeration Date:
02/17/2006

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: 207R00000X , with the licence number:  220258 , 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: J27748 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 469328 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2064090 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA12995 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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