Provider Demographics
NPI:1831124916
Name:RITTENHOUSE, JERRY R (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:RITTENHOUSE
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 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-979-0661
Mailing Address - Fax:781-979-0372
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 216
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-979-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74093208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ10977OtherBCBS
MA3119394Medicaid
MA340005511OtherRR MEDICARE
MAJ10977Medicare UPIN