Basic Information
| Provider Information | |||||||||
| NPI: | 1053492959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBENTHAL | ||||||||
| FirstName: | ABRAHAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024456002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573070896 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | DIVISION OF THORACIC SURGERY BWH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177326824 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 223872 | MA | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | MD433389 | PA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 223872 | MA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1021087210001 | 05 | PA | MEDICAID |