Provider Demographics
NPI:1417095126
Name:BOYD, MARVIN TILLMAN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:TILLMAN
Last Name:BOYD
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:PO BOX 2306
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07509-2306
Mailing Address - Country:US
Mailing Address - Phone:973-742-3300
Mailing Address - Fax:973-582-0600
Practice Address - Street 1:350 BOULVARD THE BOYD RENAL CLINIC
Practice Address - Street 2:ST. MARY'S HOSPITAL AMBULATORY SERVICES,
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-594-7800
Practice Address - Fax:973-594-7801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03839300207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0371106Medicaid
NJ441570Medicare ID - Type Unspecified
NJ0371106Medicaid