Provider Demographics
NPI:1215961206
Name:MUNZENRIDER, JOHN ELLERY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLERY
Last Name:MUNZENRIDER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:NPT 107 RADIATION ONCOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-6876
Practice Address - Fax:617-726-2098
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA322852085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Not Answered2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3059243Medicaid
MA033285OtherTUFTS HEALTH PLAN
MAM07698OtherBCBS MA
MAM07698Medicare ID - Type Unspecified
MA033285OtherTUFTS HEALTH PLAN