Provider Demographics
NPI:1750558508
Name:AIDLEN, JEREMY T (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:T
Last Name:AIDLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DIVISION OF PEDIATRIC SURGERY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-2128
Practice Address - Fax:774-443-2043
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD127112086S0120X
MA2127812086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110080669AMedicaid
MA003084901Medicare PIN
MA110080669AMedicaid