1487628418 NPI number — DR. MARK PHILIP EISENBERG MD

Table of content: DR. MARK PHILIP EISENBERG MD (NPI 1487628418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487628418 NPI number — DR. MARK PHILIP EISENBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENBERG
Provider First Name:
MARK
Provider Middle Name:
PHILIP
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:
1487628418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2022
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:
MASS GENERAL PHYSICIAN ORGANIZATION
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:
617-724-8135
Provider Business Mailing Address Fax Number:
617-724-8010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 FRUIT ST
Provider Second Line Business Practice Location Address:
MGH
Provider Business Practice Location Address City Name:
FRUIT ST
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-8135
Provider Business Practice Location Address Fax Number:
617-724-8010
Provider Enumeration Date:
02/15/2006

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: 207RA0401X , with the licence number:  54761 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 54761 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 54761 , 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: 054761 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3013103 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J05654 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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