Basic Information
| Provider Information | |||||||||
| NPI: | 1750490595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIRUSSO | ||||||||
| FirstName: | CARL | ||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MASSACHUSETTS AVENUE | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176616225 | ||||||||
| FaxNumber: | 6174922002 | ||||||||
| Practice Location | |||||||||
| Address1: | 372 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812355200 | ||||||||
| FaxNumber: | 7812351103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 111N00000X | 2117 | MA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 1144402 | 01 | MA | AETNA | OTHER | AA51163 | 01 | MA | HARVARD PILGRIM | OTHER | B21198402 | 01 | MA | CIGNA | OTHER | 319326 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 646901 | 01 | MA | UNITED HEALTH CARE | OTHER | Y36498 | 01 | MA | BCBS | OTHER |