Healthcare Provider Details

I. General information

NPI: 1437486404
Provider Name (Legal Business Name): JONATHAN MOORE BARRY BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MEDFORD ST
SOMERVILLE MA
02143-3421
US

IV. Provider business mailing address

61 MEDFORD ST
SOMERVILLE MA
02143-3421
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-3919
  • Fax:
Mailing address:
  • Phone: 617-629-3919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: