Provider Demographics
NPI:1255319430
Name:KHOURY, MARIANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:KHOURY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 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:617-559-8239
Mailing Address - Fax:
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161256208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0025243OtherNEIGHBORHOOD HEALTH
MAJ24349OtherBLUE CROSS
MAHV0128OtherHARVARD PILGRIM
MA161256OtherTUFTS
MA0158011Medicaid
MA161256OtherTUFTS
MAJ24349OtherBLUE CROSS