Provider Demographics
NPI:1457607756
Name:MASSACHUSETTS INSTITUTE OF TECHNOLOGY
Entity Type:Organization
Organization Name:MASSACHUSETTS INSTITUTE OF TECHNOLOGY
Other - Org Name:MIT MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-258-6609
Mailing Address - Street 1:77 MASSACHUSETTS AVE # E23-431
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4301
Mailing Address - Country:US
Mailing Address - Phone:617-258-6609
Mailing Address - Fax:
Practice Address - Street 1:25 CARLETON ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1323
Practice Address - Country:US
Practice Address - Phone:617-253-4481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2863261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY61353OtherBCBS PHYSICAL THERAPY
MAY61353OtherBCBS PHYSICAL THERAPY
MAW20051Medicare Oscar/Certification
MA0970900001Medicare NSC