Provider Demographics
NPI:1578632493
Name:COLWELL, AMY S (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:COLWELL
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:617-643-5963
Mailing Address - Fax:617-643-5964
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-643-5963
Practice Address - Fax:617-643-5964
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA207052208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110079072/AMedicaid
MA000558101Medicare PIN