=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730317413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMBRIDGE CARDIOVASCULAR ULTRASOUND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2009
-----------------------------------------------------
Last Update Date | 07/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1493 CAMBRIDGE ST
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-826-0053
-----------------------------------------------------
Fax | 781-826-0054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 E EMERSON ST
-----------------------------------------------------
City | MELROSE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02176-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-826-0053
-----------------------------------------------------
Fax | 781-826-0054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | KIMBERLY A GREENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-826-0053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 042679
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------