Provider Demographics
NPI:1790747236
Name:KIERAN, MARK WILLIAM (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:KIERAN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BINNEY ST
Mailing Address - Street 2:ROOM SW331
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6013
Mailing Address - Country:US
Mailing Address - Phone:617-632-4907
Mailing Address - Fax:617-632-4897
Practice Address - Street 1:44 BINNEY ST
Practice Address - Street 2:ROOM SW331
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6013
Practice Address - Country:US
Practice Address - Phone:617-632-4907
Practice Address - Fax:617-632-4897
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA761462080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8545845OtherCIGNA
076146OtherTUFTS
2929111OtherAETNA US HEALTHCARE
F33356DFOtherHPHC DFCI ONLY
23303OtherFALLON COMMUNITY HEALTH
000000026066OtherBMC HEALTHNET
3138950OtherMASSHEALTH
7505047OtherUNITED HEALTH CARE
370013224OtherRR MEDICARE BINNEY MED
J31260OtherMA BCBS
J12662Medicare ID - Type Unspecified
2929111OtherAETNA US HEALTHCARE