Provider Demographics
NPI:1881679462
Name:THEALL, KATHY (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:THEALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST # 245
Mailing Address - Street 2:DEPARTMENT OF HEMATOLOGY/ ONCOLOGY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-8148
Mailing Address - Fax:617-636-8538
Practice Address - Street 1:800 WASHINGTON ST # 245
Practice Address - Street 2:DEPARTMENT OF HEMATOLOGY/ ONCOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-8148
Practice Address - Fax:617-636-8538
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10105207RH0003X
MA81285207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002761Medicaid
MA2127091Medicaid
RIG93978Medicare UPIN
MAA40909Medicare PIN
RI119002761Medicare ID - Type UnspecifiedMEDICARE