Provider Demographics
NPI:1437237856
Name:CAVERNOSA CORPORATION
Entity Type:Organization
Organization Name:CAVERNOSA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGENTALER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:617-277-5000
Mailing Address - Street 1:ONE BROOKLINE PLACE
Mailing Address - Street 2:STE 624
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-277-5000
Mailing Address - Fax:617-277-5444
Practice Address - Street 1:ONE BROOKLINE PLACE
Practice Address - Street 2:STE 624
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-277-5000
Practice Address - Fax:617-277-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9702261Medicaid
MA9702261Medicaid