Healthcare Provider Details

I. General information

NPI: 1568505964
Provider Name (Legal Business Name): KENNETH M HUTTNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INTERLENKIN GENETRICS, INC. 135 BEAVER STREET
WALTHAM MA
02452
US

IV. Provider business mailing address

840 NEWTON ST
CHESTNUT HILL MA
02467-2643
US

V. Phone/Fax

Practice location:
  • Phone: 781-419-4745
  • Fax:
Mailing address:
  • Phone: 781-419-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number59722
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: