Provider Demographics
NPI:1861422966
Name:FLAHERTY, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:FLAHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT STREET
Mailing Address - Street 2:LAWRENCE HOUSE 202
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-643-5817
Mailing Address - Fax:617-724-3166
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:LAWRENCE HOUSE 202
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-643-5817
Practice Address - Fax:617-724-3166
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110082653AMedicaid
MA001188202OtherMEDICARE ACD
MA001188201OtherMEDICARE PTAN