Provider Demographics
NPI:1639136591
Name:MACDONALD, NATHAN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RAYMOND
Last Name:MACDONALD
Suffix:
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 1:295 VARNUM AVE
Mailing Address - Street 2:LOWELL GENERAL HOSPITAL EMERGENCY DEPARTMENT
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2134
Mailing Address - Country:US
Mailing Address - Phone:978-937-6161
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:LOWELL GENERAL HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2134
Practice Address - Country:US
Practice Address - Phone:978-937-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA155399207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2143577Medicaid
MAJ42432OtherBLUE SHIELD
MAJ42432OtherBLUE SHIELD