Provider Demographics
NPI:1619045341
Name:KENNETH MACOUL MD INC
Entity Type:Organization
Organization Name:KENNETH MACOUL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACOUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-685-5366
Mailing Address - Street 1:280 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-685-5366
Mailing Address - Fax:978-685-4867
Practice Address - Street 1:280 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840
Practice Address - Country:US
Practice Address - Phone:978-685-5366
Practice Address - Fax:978-685-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
15777OtherHARVARD
MA9701231Medicaid
702380OtherTUFTS
0020957OtherNEIGHBORHOOD HEALTH
M88005OtherBCBS
29711OtherFALLON
988756OtherNETWORK HEALTH
0020957OtherNEIGHBORHOOD HEALTH
M88005OtherBCBS
29711OtherFALLON