Provider Demographics
NPI:1376510271
Name:PHALEN, JEAN R (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:R
Last Name:PHALEN
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 1:1450 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2690
Mailing Address - Country:US
Mailing Address - Phone:781-449-0020
Mailing Address - Fax:781-449-3181
Practice Address - Street 1:1450 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2690
Practice Address - Country:US
Practice Address - Phone:781-449-0020
Practice Address - Fax:781-449-3181
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA693126OtherHARVARD PILGRIM ID
MA3024512Medicaid
MAJ06766OtherBLUE CROSS ID
MA057337OtherTUFTS HEALTH PLAN ID
MA693126OtherHARVARD PILGRIM ID
MAJ06766Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID