Provider Demographics
NPI:1659337657
Name:KIRSCHENBAUM, IRA N (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:N
Last Name:KIRSCHENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5100
Practice Address - Fax:781-306-5379
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-05-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA303572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6031309-001OtherCIGNA
MA0146749Medicaid
MD030357OtherTUFTS HEALTH PLAN
MA0017155OtherNEIGHBORHOOD HEALTH
MAC04608OtherBLUE CROSS BLUE SHIELD
MA300126057OtherRAILROAD
MD6031309-001OtherHEALTHSOURCE
MAR121OtherHARVARD PILGRIM
MA0146749Medicaid
MA6031309-001OtherCIGNA