Healthcare Provider Details

I. General information

NPI: 1700862745
Provider Name (Legal Business Name): KEVAN L HARTSHORN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 HARRISON AVE MOAKLEY, 3RD FLOOR
BOSTON MA
02118-2905
US

IV. Provider business mailing address

720 HARRISON AVE DOB-503
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6248
  • Fax: 617-638-5756
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number49999
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number49999
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: