Healthcare Provider Details

I. General information

NPI: 1245218353
Provider Name (Legal Business Name): BENJAMIN A KRUSKAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6000
  • Fax: 617-629-6070
Mailing address:
  • Phone: 617-629-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number71820
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number71820
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: