Provider Demographics
NPI:1386628345
Name:JOUNG, JAE KEITH (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:KEITH
Last Name:JOUNG
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
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Other - Last Name:
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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:GRB 235 PATHOLOGY ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-8887
Practice Address - Fax:617-726-5684
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA204131207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0102911Medicaid
MA204131OtherTUFTS HEALTH PLAN
MAJ22414OtherBCBS MA
H15400Medicare UPIN
MAA31032Medicare ID - Type Unspecified