Healthcare Provider Details

I. General information

NPI: 1013278902
Provider Name (Legal Business Name): ROBERT JOHN TAVARES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HERRICK ST LAHEY AT BEVERLY HOSPITAL
BEVERLY MA
01915-1790
US

IV. Provider business mailing address

85 HERRICK ST LAHEY AT BEVERLY HOSPITAL
BEVERLY MA
01915-1790
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-3000
  • Fax: 978-816-3052
Mailing address:
  • Phone: 978-922-3000
  • Fax: 978-816-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number264883
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number252213
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16852
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: