Provider Demographics
NPI:1477547529
Name:BEANTOWN PHYSIO, INC
Entity Type:Organization
Organization Name:BEANTOWN PHYSIO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ PHYSICAL THERPIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:GHOSTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:617-232-7246
Mailing Address - Street 1:33 POND AVE
Mailing Address - Street 2:SUITE 107B
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7163
Mailing Address - Country:US
Mailing Address - Phone:617-232-7246
Mailing Address - Fax:617-232-5196
Practice Address - Street 1:33 POND AVE
Practice Address - Street 2:SUITE 107B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7163
Practice Address - Country:US
Practice Address - Phone:617-232-7246
Practice Address - Fax:617-232-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16266225100000X
MA8336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPT0174Medicare ID - Type UnspecifiedGROUP NUMBER
MEY68141Medicare ID - Type UnspecifiedPAUL GHOSTLAW, PT
MAY69049Medicare ID - Type UnspecifiedJESSICA HINERTH, PT