1760436364 NPI number — DR. EVA MICHELLE SELHUB M.D.

Table of content: DR. EVA MICHELLE SELHUB M.D. (NPI 1760436364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760436364 NPI number — DR. EVA MICHELLE SELHUB M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELHUB
Provider First Name:
EVA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1760436364
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:
PO BOPX 9142
Provider Second Line Business Mailing Address:
MASS GENERAL PHYSICIANS ORGANIZATION INC
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:
617-724-0287
Provider Business Mailing Address Fax Number:
617-726-2894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 BOYLSTON ST
Provider Second Line Business Practice Location Address:
MIND/BODY MEDICAL INSTITUTE
Provider Business Practice Location Address City Name:
CHESTNUT HILL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02467-2508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-991-0102
Provider Business Practice Location Address Fax Number:
617-991-0112
Provider Enumeration Date:
05/19/2006

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: 207R00000X , with the licence number:  152152 , 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: 3166104 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J17746 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".