Provider Demographics
NPI:1528044096
Name:MEYER, JACK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:MEYER
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:RADIOLOGY BRIGHAM & WOMENS HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-6269
Mailing Address - Fax:617-525-7333
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:RADIOLOGY BRIGHAM & WOMENS HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-6269
Practice Address - Fax:617-525-7333
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA306502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2085151Medicaid
MAM07917OtherBLUE CROSS BLUE SHIELD
MA760044OtherTUFTS HEALTH PLAN
B75669Medicare UPIN
MA760044OtherTUFTS HEALTH PLAN