Provider Demographics
NPI:1073569273
Name:WEAVER, SUSAN B (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:1611 CAMBRIDGE ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4302
Practice Address - Country:US
Practice Address - Phone:617-661-5100
Practice Address - Fax:617-661-5226
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-05-26
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Provider Licenses
StateLicense IDTaxonomies
MA227417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2125811Medicaid
MAA40681Medicare PIN