Provider Demographics
NPI:1073503371
Name:MARILL, KEITH AUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:AUSTIN
Last Name:MARILL
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 ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-643-8595
Mailing Address - Fax:617-724-0917
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-643-8595
Practice Address - Fax:617-724-0917
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214889207P00000X, 207R00000X
PAMD448123207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ24824OtherBCBS MA
MA451736OtherTUFTS HEALTH PLAN
MA0199010Medicaid
MA451736OtherTUFTS HEALTH PLAN
MAA34091Medicare ID - Type Unspecified