MEDICARE: DR. NATALIA GANSON-MYSHKIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	75596	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J12678	OTHER	MA	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	64121	OTHER	MA	HARVARD PILGRIM HEALTHCAR
4	B10065602	OTHER		CIGNA HEALTHCARE
5	075596	OTHER		TUFTS ASSOCIATED HEALTH P

General Provider Information

NPI Number	:	1457340515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATALIA GANSON-MYSHKIN M.D.

Provider Business Mailing Address
First Line	:	2110 DORCHESTER AVE STE 311
Second Line	:	SETON MEDICAL OFFICE BUILDING
City	:	DORCHESTER
State	:	MA
Zip	:	02124-5615
Country	:	US
Telephone Number	:	617-296-0456
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 DORCHESTER AVE
Second Line	:
City	:	DORCHESTER CENTER
State	:	MA
Zip	:	02124-5628
Country	:	US
Telephone Number	:	617-436-3786
Fax Number	:	617-296-5778

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	09/02/2015

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Directions to “ DR. NATALIA GANSON-MYSHKIN M.D.” Practice Location

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