Provider Demographics
NPI:1336488774
Name:FELLSWAY PEDIATRICS, PC
Entity Type:Organization
Organization Name:FELLSWAY PEDIATRICS, PC
Other - Org Name:BREWER NYSTUEN PEDIATRIC ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-665-4364
Mailing Address - Street 1:548 LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3226
Mailing Address - Country:US
Mailing Address - Phone:781-665-4364
Mailing Address - Fax:781-662-2284
Practice Address - Street 1:548 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3226
Practice Address - Country:US
Practice Address - Phone:781-665-4364
Practice Address - Fax:781-662-2284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79158208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9787119Medicaid
MA9787119Medicaid