Basic Information
| Provider Information | |||||||||
| NPI: | 1417942129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AUERBACH | ||||||||
| FirstName: | JEROME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174211000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174211000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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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 | 174400000X | 44121 | MA | N | Other Service Providers | Specialist | 2085R0202X | 44121 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 117208 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2070154 | 05 | MA | MEDICAID | 00579915 | 05 | NY | MEDICAID | 677T91 | 01 | NY | MEDICARE | OTHER |