Healthcare Provider Details

I. General information

NPI: 1386628345
Provider Name (Legal Business Name): JAE KEITH JOUNG MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST GRB 235 PATHOLOGY ASSOCIATES
BOSTON MA
02114-2696
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8887
  • Fax: 617-726-5684
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number204131
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: