Provider Demographics
NPI:1558359190
Name:BRIAN KWON, MD PC
Entity Type:Organization
Organization Name:BRIAN KWON, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-754-6486
Mailing Address - Street 1:125 PARKER HILL AVE
Mailing Address - Street 2:CONVERSE 4
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:617-754-6586
Mailing Address - Fax:617-754-5593
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:CONVERSE 4
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-6586
Practice Address - Fax:617-754-5593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216761207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18822OtherBCBS MA
MA470668OtherTUFTS
MAAA16221OtherHPHC
MA9733370Medicaid
MA470668OtherTUFTS
MAM214790Medicare ID - Type Unspecified