Provider Demographics
NPI:1578083119
Name:SRK MD, LLC
Entity Type:Organization
Organization Name:SRK MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-684-0600
Mailing Address - Street 1:12 BYPASS RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-1202
Mailing Address - Country:US
Mailing Address - Phone:781-259-0222
Mailing Address - Fax:781-259-4050
Practice Address - Street 1:210 BEAR HILL RD STE 304
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1025
Practice Address - Country:US
Practice Address - Phone:781-684-0600
Practice Address - Fax:781-684-0601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEVEN R. KANNER, MD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-25
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty