Provider Demographics
NPI:1790741155
Name:KORNGUTH, PHYLLIS J (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:KORNGUTH
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First 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 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA412812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ21332OtherBLUE CROSS BLUE SHIELD
MDP00272094OtherRAILROAD
MA0015804OtherNEIGHBORHOOD HEALTH
MA4814101OtherCIGNA
MDAA43706OtherHARVARD PILGRIM
MA3196097Medicaid
MA041281OtherTUFTS HEALTH PLAN
MAA30005Medicare ID - Type Unspecified
MDP00272094OtherRAILROAD