Provider Demographics
NPI:1396780904
Name:PLOVNICK, HERBERT S (MD)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:S
Last Name:PLOVNICK
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 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5345
Practice Address - Fax:781-306-5015
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38333207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM09787OtherBLUE CROSS
MA705817OtherTUFTS
MA0119873Medicaid
MA0015311OtherNEIGHBRHOOD HEALTH
MAV534OtherHARVARD PILGRIM
MAM09787Medicare PIN
MA0119873Medicaid