Provider Demographics
NPI: | 1700862745 |
---|---|
Name: | HARTSHORN, KEVAN L (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KEVAN |
Middle Name: | L |
Last Name: | HARTSHORN |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 720 HARRISON AVE |
Mailing Address - Street 2: | DOB-503 |
Mailing Address - City: | BOSTON |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02118 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 830 HARRISON AVE |
Practice Address - Street 2: | MOAKLEY, 3RD FLOOR |
Practice Address - City: | BOSTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02118-2905 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-638-6248 |
Practice Address - Fax: | 617-638-5756 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-21 |
Last Update Date: | 2017-09-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 49999 | 207RH0000X, 207RX0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No | 207RH0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 110064373A | Medicaid | |
MA | UX7084 | Medicare PIN | |
MA | J03299 | Medicare PIN | |
MA | 110064373A | Medicaid |