Provider Demographics
NPI:1831124601
Name:GILLICK, MURIEL R (MD)
Entity Type:Individual
Prefix:
First Name:MURIEL
Middle Name:R
Last Name:GILLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-559-8374
Practice Address - Fax:617-421-3487
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48178207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE05954OtherBLUE CROSS
MA0186007Medicaid
MA712306OtherTUFTS
MAAA53OtherHARVARD PILGRIM
MA0030868OtherNEIGHBORHOOD HEATLH
MAE05954OtherBLUE CROSS
MA0030868OtherNEIGHBORHOOD HEATLH