Provider Demographics
NPI:1821070160
Name:NATHAN, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:NATHAN
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:781-485-6300
Mailing Address - Fax:781-485-6392
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:RHC REVERE HEALTHCARE CENTER
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:781-485-6300
Practice Address - Fax:781-485-6392
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA72450207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA072450OtherTUFTS HEALTH PLAN
MA3078531Medicaid
MAJ11198OtherBCBS MA
MA072450OtherTUFTS HEALTH PLAN
MAJ11198Medicare PIN