Provider Demographics
NPI:1679603757
Name:STEVEN R. KANNER, MD, LLC
Entity type:Organization
Organization Name:STEVEN R. KANNER, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-684-0600
Mailing Address - Street 1:210 BEAR HILL RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1025
Mailing Address - Country:US
Mailing Address - Phone:781-684-0600
Mailing Address - Fax:781-684-0601
Practice Address - Street 1:210 BEAR HILL RD
Practice Address - Street 2:SUITE 304
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1025
Practice Address - Country:US
Practice Address - Phone:781-684-0600
Practice Address - Fax:781-684-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB49032Medicare PIN