Provider Demographics
NPI:1437149093
Name:MACCOLLIN, MIA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:M
Last Name:MACCOLLIN
Suffix:
Gender:F
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 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:149 13TH ST
Practice Address - Street 2:6TH FLOOR CYN 149 6
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-2020
Practice Address - Country:US
Practice Address - Phone:617-726-7856
Practice Address - Fax:617-724-9620
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73495208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA727826OtherTUFTS HEALTH PLAN
MAJ30964OtherBCBS MA
MA3131360Medicaid
MA3131360Medicaid
F97281Medicare UPIN