Provider Demographics
NPI:1538113477
Name:FABRICK, KURT CHARLES (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:CHARLES
Last Name:FABRICK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
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Mailing Address - Street 1:1 CLINTON PATH
Mailing Address - Street 2:UNIT #1
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4207
Mailing Address - Country:US
Mailing Address - Phone:617-640-1402
Mailing Address - Fax:617-383-5732
Practice Address - Street 1:1 CLINTON PATH
Practice Address - Street 2:UNIT #1
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4207
Practice Address - Country:US
Practice Address - Phone:617-640-1402
Practice Address - Fax:617-383-5732
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA79759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3135691Medicaid
MA04-3581957OtherTAX ID
MA79759OtherMA STATE LICENSE NUMBER
MA3135691Medicaid
MA79759OtherMA STATE LICENSE NUMBER