Provider Demographics
NPI:1417116054
Name:WILSON, MAIREAD RYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAIREAD
Middle Name:RYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAIREAD
Other - Middle Name:RYNN
Other - Last Name:DONAHUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6000
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:S WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246120208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
04-2297845OtherTRICARE
MAAA436677OtherHARVARD PILGRIM
3975418OtherCIGNA
MA1417116054OtherNEIGHBORHOOD HEALTH PLAN
04-2297845OtherUNITED HEALTH CARE
04-2297845OtherMULTI-PLAN
9984652OtherAETNA
MAJ48728OtherBCBSMA
1417116054OtherFALLON COMMUNITY HEALTH PLAN
04-2297845OtherHCVM
04-2297845OtherUNITED HEALTH CARE