Provider Demographics
NPI:1497866339
Name:LALLY, KATE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:MARIE
Last Name:LALLY
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 1:450 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-6464
Mailing Address - Fax:617-632-6180
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-6464
Practice Address - Fax:617-632-6180
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425183207R00000X
RIMD13953207RH0002X
MA275932207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2406111000OtherINDEPENDENCE BLUE CROSS
PALA1739656OtherHIGHMARK BS
091957NNKMedicare ID - Type Unspecified
2406111000OtherINDEPENDENCE BLUE CROSS