Provider Demographics
NPI:1538232871
Name:MT AUBURN THERAPEUTIC ENDOSCOPY
Entity type:Organization
Organization Name:MT AUBURN THERAPEUTIC ENDOSCOPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUYMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-661-0221
Mailing Address - Street 1:ONE ARSENAL MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-673-1851
Mailing Address - Fax:617-499-5579
Practice Address - Street 1:300 MOUNT AUBURN ST
Practice Address - Street 2:STE 405
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5600
Practice Address - Country:US
Practice Address - Phone:617-661-0221
Practice Address - Fax:617-661-3862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71422207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17551OtherBLUE CROSS GROUP
MA3052788Medicaid
MA3052788Medicaid
MAE17583Medicare UPIN