1841417433 NPI number — DR. RONENN ROUBENOFF MD, MHS

Table of content: DR. RONENN ROUBENOFF MD, MHS (NPI 1841417433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841417433 NPI number — DR. RONENN ROUBENOFF MD, MHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUBENOFF
Provider First Name:
RONENN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MHS
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:
1841417433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
602-321A
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-871-5044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 CAMBRIDGE CTR
Provider Second Line Business Practice Location Address:
B6A-6
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02142-1453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-679-6450
Provider Business Practice Location Address Fax Number:
617-679-3518
Provider Enumeration Date:
04/18/2007

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: 207RR0500X , with the licence number:  72474 , 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)





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