Provider Demographics
NPI:1053386771
Name:GORENBURG, IDA P (MD)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:P
Last Name:GORENBURG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5220
Practice Address - Fax:781-431-5526
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA220258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ27748OtherBLUE CROSS
MA469328OtherTUFTS
MA2064090Medicaid
MAAA12995OtherHARVARD PILGRIM
MAAA12995OtherHARVARD PILGRIM
MAI10351Medicare UPIN