1114045382 NPI number — DR. MICHAEL TERRENCE MYERS JR. MD, MBA

Table of content: DR. MICHAEL TERRENCE MYERS JR. MD, MBA (NPI 1114045382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114045382 NPI number — DR. MICHAEL TERRENCE MYERS JR. MD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
MICHAEL
Provider Middle Name:
TERRENCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD, MBA
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:
1114045382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 CHANNEL CTR ST
Provider Second Line Business Mailing Address:
UNIT #402
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02210-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-433-3014
Provider Business Mailing Address Fax Number:
781-449-3776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 FOURTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEEDHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02494-2725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-433-3014
Provider Business Practice Location Address Fax Number:
781-449-3776
Provider Enumeration Date:
03/27/2007

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: 207R00000X , with the licence number:  57242 , 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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