Provider Demographics
NPI: | 1356332944 |
---|---|
Name: | AVERY, LAURA LOUISE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | LAURA |
Middle Name: | LOUISE |
Last Name: | AVERY |
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: | PO BOX 9142 |
Mailing Address - Street 2: | MASS GENERAL PHYSICIAN ORGANIZATION |
Mailing Address - City: | CHARLESTOWN |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02129-9142 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 617-724-0287 |
Mailing Address - Fax: | 617-726-2894 |
Practice Address - Street 1: | 55 FRUIT ST |
Practice Address - Street 2: | RADIOLOGICAL ASSOCIATES FND 2 |
Practice Address - City: | BOSTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02114-2696 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-726-5244 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2005-11-02 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 219266 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 468144 | Other | TUFTS HEALTH PLAN |
MA | 2101432 | Medicaid | |
MA | J28606 | Other | BCBS MA |
MA | J28606 | Other | BCBS MA |
MA | 2101432 | Medicaid |