Healthcare Provider Details

I. General information

NPI: 1578053328
Provider Name (Legal Business Name): KEVIN BERSELL MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6106
US

IV. Provider business mailing address

75 FRANCIS ST
BOSTON MA
02115-6110
US

V. Phone/Fax

Practice location:
  • Phone: 603-490-5660
  • Fax:
Mailing address:
  • Phone: 617-732-5775
  • Fax: 617-264-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1015995
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: