1477543031 NPI number — DR. LAWRENCE T GEOGHEGAN MD

Table of content: DR. LAWRENCE T GEOGHEGAN MD (NPI 1477543031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477543031 NPI number — DR. LAWRENCE T GEOGHEGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEOGHEGAN
Provider First Name:
LAWRENCE
Provider Middle Name:
T
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:
1477543031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
MIT MEDICAL DEPARTMENT E23-300
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-4301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-253-4988
Provider Business Mailing Address Fax Number:
617-253-7265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MASSACHUSETTS AVE
Provider Second Line Business Practice Location Address:
MIT MEDICAL DEPARTMENT E23-300
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02139-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-253-4988
Provider Business Practice Location Address Fax Number:
617-253-7265
Provider Enumeration Date:
10/25/2005

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: 208600000X , with the licence number:  30208 , 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: 0175161 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: B33229 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: LAM12968 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 030208 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".




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