=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487033288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERBERT & KONG LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 CONCORD AVE SUITE 104
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02138-1056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-366-9399
-----------------------------------------------------
Fax | 857-263-5810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 CONCORD AVE, SUITE 104
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02138-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-366-9399
-----------------------------------------------------
Fax | 857-263-5810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-DIRECTOR
-----------------------------------------------------
Name | DR. MARTHA R. HERBERT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 857-366-9399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 150498
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------