Basic Information
Provider Information
NPI: 1174513899
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BECKER
FirstName: STEPHAN
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 460 TOTTEN POND RD
Address2: C/O MZI
City: WALTHAM
State: MA
PostalCode: 024511991
CountryCode: US
TelephoneNumber: 7818909933
FaxNumber: 7818909950
Practice Location
Address1: 88 WASHINGTON ST
Address2: ATTN: EMERGENCY DEPT
City: TAUNTON
State: MA
PostalCode: 027802465
CountryCode: US
TelephoneNumber: 5088287108
FaxNumber: 5088287158
Other Information
ProviderEnumerationDate: 10/25/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207PE0004X55003MAY Allopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services

ID Information
IDTypeStateIssuerDescription
43627401MAHPHCOTHER
75413101MATUFTSOTHER
J0601101MABCBSOTHER
301539405MA MEDICAID


Home