Provider Demographics
NPI:1508047531
Name:PHILIP J DOHERTY MD FACC PC
Entity Type:Organization
Organization Name:PHILIP J DOHERTY MD FACC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-696-0430
Mailing Address - Street 1:100 HIGHLAND STREET
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-0268
Mailing Address - Country:US
Mailing Address - Phone:617-696-0430
Mailing Address - Fax:617-698-1625
Practice Address - Street 1:100 HIGHLAND STREET
Practice Address - Street 2:SUITE 106
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-0268
Practice Address - Country:US
Practice Address - Phone:617-696-0430
Practice Address - Fax:617-698-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM12648OtherBLUE CROSS BLUE SHIELD
MAM12648OtherBLUE CROSS BLUE SHIELD