1790944965 NPI number — DR. REBECCA G MISHURIS MD

Table of content: DR. REBECCA G MISHURIS MD (NPI 1790944965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790944965 NPI number — DR. REBECCA G MISHURIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISHURIS
Provider First Name:
REBECCA
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROCHOW
Provider Other First Name:
REBECCA
Provider Other Middle Name:
MIRIAM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790944965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 HARRISON AVENUE
Provider Second Line Business Mailing Address:
DOB 503
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 ALBANY STREET
Provider Second Line Business Practice Location Address:
SHAPIRO 5, SUITE B
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-5951
Provider Business Practice Location Address Fax Number:
617-414-1577
Provider Enumeration Date:
06/03/2008

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:  247110 , 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: 110089202A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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