Provider Demographics
NPI:1245228105
Name:HILLSTROM, MARY M (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:HILLSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1518882085R0202X
RI86602085R0202X
RIMD086602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
008660OtherTUFTS
003109817OtherCT MED ASSISTANCE
007006235OtherHOSPITAL PIN
008660OtherBCBS
240081OtherRIH PILGRIM
3200388OtherHEALTHY START
MA3200388Medicaid
300084316OtherRR MEDICARE
000000001988OtherNHPRI
004950OtherBLUE CHIP
7003975OtherRI MEDICAL ASSISTANCE
8660OtherFEP BLUE CROSS
1600203OtherUNITED HEALTH PLANS
720071101OtherCIGNA
007006235OtherHOSPITAL PIN
240081OtherRIH PILGRIM