Provider Demographics
NPI:1619545688
Name:SQUARE KNOT PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:SQUARE KNOT PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIOT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HEHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-468-4247
Mailing Address - Street 1:240 MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2519
Mailing Address - Country:US
Mailing Address - Phone:617-468-4245
Mailing Address - Fax:617-468-4556
Practice Address - Street 1:240 MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2519
Practice Address - Country:US
Practice Address - Phone:617-468-4245
Practice Address - Fax:617-468-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty