1245221894 NPI number — DR. JACK WITTENBERG MD

Table of content: BRIAN MCREE (NPI 1609578004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245221894 NPI number — DR. JACK WITTENBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITTENBERG
Provider First Name:
JACK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1245221894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9142
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-726-8380
Provider Business Mailing Address Fax Number:
617-726-4891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 FRUIT ST
Provider Second Line Business Practice Location Address:
FND 2
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-726-8396
Provider Business Practice Location Address Fax Number:
617-726-4891
Provider Enumeration Date:
11/02/2005

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: 2085R0202X , with the licence number:  28711 , 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: 0194255 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 725096 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M07089 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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