Basic Information
| Provider Information | |||||||||
| NPI: | 1487880084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIVENS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 PARK ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024466257 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176677000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2009 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 250317 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 250317 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 2083A0300X | 250317 | MA | N |
ID Information
| ID | Type | State | Issuer | Description | 110093064A | 05 | MA | MEDICAID |