Basic Information
| Provider Information | |||||||||
| NPI: | 1760477046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 SHORE ROAD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817291810 | ||||||||
| FaxNumber: | 9786830663 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 SHORE ROAD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817291810 | ||||||||
| FaxNumber: | 9786830663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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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 | 207Q00000X | 209739 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1303775 | 05 | MA | MEDICAID |