Provider Demographics
NPI:1255354049
Name:ALTEKRUSE, PHILIP D (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
Last Name:ALTEKRUSE
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 1:19 LONGFELLOW RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4737
Mailing Address - Country:US
Mailing Address - Phone:617-576-0699
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:859 WILLARD ST
Practice Address - Street 2:SUITE 430
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7482
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA572602084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY02415OtherBLUE CROSS
MAY02415Medicare ID - Type Unspecified
MAY02415OtherBLUE CROSS