Provider Demographics
NPI:1538141965
Name:BLACKWELL, MARY T (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:THIERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:ONE BOSTON MEDCIAL CENTER PLACE
Mailing Address - Street 2:DIVISION OF PEDIATRICS DOWLING 3 SOUTH
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-414-5170
Mailing Address - Fax:617-414-3803
Practice Address - Street 1:DOWLING 3 SOUTH ONE BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:CHILD HEALTH FOUNDATION OF BOSTON
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5170
Practice Address - Fax:617-414-3803
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78516208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3114147Medicaid
J14150Medicare ID - Type Unspecified
MA3114147Medicaid