Basic Information
| Provider Information | |||||||||
| NPI: | 1649512195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETTERER | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D., M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 WYMAN ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021301904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195942307 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 DEACONESS RD | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176677000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 270150 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.