Provider Demographics
NPI:1275523490
Name:MICHAELSON, MARC DROR (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:DROR
Last Name:MICHAELSON
Suffix:
Gender:M
Credentials:MD PHD
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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:617-726-1594
Mailing Address - Fax:617-726-3440
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:COX 640 HEMATOLOGY ONCOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-5187
Practice Address - Fax:617-724-3166
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-08-01
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Provider Licenses
StateLicense IDTaxonomies
MA159790207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA159790OtherTUFTS HEALTH PLAN
MAJ24713OtherBCBS MA
MA0169391Medicaid
MAA29573Medicare ID - Type Unspecified
MA0169391Medicaid