Provider Demographics
NPI:1275601874
Name:SMALL, KIRSTIN MARIE SHU (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTIN
Middle Name:MARIE SHU
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIRSTIN
Other - Middle Name:MARIE
Other - Last Name:SHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:RADIOLOGY/BRIGHAM AND WOMEN'S HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-7537
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:RADIOLOGY/BRIGHAM AND WOMEN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-7537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2186552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1275601874Medicare PIN