Provider Demographics
NPI:1326040080
Name:KEARNEY, GARY P (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:KEARNEY
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 1:319 LONGWOOD AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5728
Mailing Address - Country:US
Mailing Address - Phone:617-277-9889
Mailing Address - Fax:617-232-7571
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-277-0100
Practice Address - Fax:617-232-7571
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA31977208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2049864Medicaid
MAC06017Medicare ID - Type Unspecified
MAA40505Medicare UPIN