Provider Demographics
NPI:1467641704
Name:NELLI G DORMAN MD PC
Entity Type:Organization
Organization Name:NELLI G DORMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PC
Authorized Official - Prefix:
Authorized Official - First Name:NELLI
Authorized Official - Middle Name:G
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-791-6351
Mailing Address - Street 1:8 NOTCHBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545
Mailing Address - Country:US
Mailing Address - Phone:508-865-0890
Mailing Address - Fax:508-865-5226
Practice Address - Street 1:189 MAY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602
Practice Address - Country:US
Practice Address - Phone:508-791-6391
Practice Address - Fax:508-865-5226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9749471Medicaid
MA9749471Medicaid