Basic Information
| Provider Information | |||||||||
| NPI: | 1659337657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRSCHENBAUM | ||||||||
| FirstName: | IRA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174212508 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 CITY HALL MALL | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021554754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813065100 | ||||||||
| FaxNumber: | 7813065379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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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 | 2085R0202X | 30357 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 6031309-001 | 01 | MA | CIGNA | OTHER | 0146749 | 05 | MA | MEDICAID | 030357 | 01 | MD | TUFTS HEALTH PLAN | OTHER | 0017155 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | C04608 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 300126057 | 01 | MA | RAILROAD | OTHER | 6031309-001 | 01 | MD | HEALTHSOURCE | OTHER | R121 | 01 | MA | HARVARD PILGRIM | OTHER |