Provider Demographics
NPI:1548241292
Name:ELLISON, RICHARD T III (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:ELLISON
Suffix:III
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-6053
Practice Address - Fax:508-334-6412
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75165207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3085821Medicaid
MA3085821Medicaid
MAGX2604Medicare PIN