Basic Information
| Provider Information | |||||||||
| NPI: | 1730168378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKARUSHKA | ||||||||
| FirstName: | IHOR | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598053 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 ESSEX CENTER DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019602902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789774000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 41791 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0015158 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | D28154 | 01 | MA | BLUE CROSS | OTHER | 041791 | 01 | MA | TUFTS | OTHER | PP485 | 01 | MA | HARVARD PILGRIM | OTHER | 2070006 | 05 | MA | MEDICAID |