Basic Information
Provider Information | |||||||||
NPI: | 1790741155 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KORNGUTH | ||||||||
FirstName: | PHYLLIS | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 133 BROOKLINE AVE | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022153904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174211000 | ||||||||
FaxNumber: | 6174216084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 01/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41281 | MA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | J21332 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | P00272094 | 01 | MD | RAILROAD | OTHER | 0015804 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 4814101 | 01 | MA | CIGNA | OTHER | AA43706 | 01 | MD | HARVARD PILGRIM | OTHER | 3196097 | 05 | MA |   | MEDICAID | 041281 | 01 | MA | TUFTS HEALTH PLAN | OTHER |