Provider Demographics
NPI:1639261993
Name:PLOVNICK, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:PLOVNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MOUNT AUBURN ST
Mailing Address - Street 2:HARVARD UNIVERSITY HEALTH SERVICE
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4960
Mailing Address - Country:US
Mailing Address - Phone:617-496-8700
Mailing Address - Fax:617-495-6059
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:HARVARD UNIVERSITY HEALTH SERVICE
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-496-8700
Practice Address - Fax:617-495-6059
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1064901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04221Medicare ID - Type Unspecified