Provider Demographics
NPI:1033292636
Name:EMMERICH, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:EMMERICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4010
Mailing Address - Country:US
Mailing Address - Phone:617-433-9601
Mailing Address - Fax:617-445-6538
Practice Address - Street 1:30 NORTHAMPTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4010
Practice Address - Country:US
Practice Address - Phone:617-433-9601
Practice Address - Fax:617-445-6538
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3082865Medicaid
MAAA19012OtherHARVARD PILGRIM NUMBER
MIJ10694OtherBCBS NUMBER
MAAA19012OtherHARVARD PILGRIM NUMBER
MAE73687Medicare UPIN