Healthcare Provider Details

I. General information

NPI: 1629165014
Provider Name (Legal Business Name): MICHAEL PHILIP MENKE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 COLUMBIA RD
DORCHESTER MA
02125-2424
US

IV. Provider business mailing address

32 OAKVIEW TER #2
JAMAICA PLAIN MA
02130-4902
US

V. Phone/Fax

Practice location:
  • Phone: 617-740-8184
  • Fax:
Mailing address:
  • Phone: 617-522-5759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number169059
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: