Provider Demographics
NPI:1861482945
Name:GOLDHAMER, MARY ELLEN JOY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:JOY
Last Name:GOLDHAMER
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: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:617-724-6610
Mailing Address - Fax:617-724-6649
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WAC 108
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-2707
Practice Address - Fax:617-724-0189
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ28605OtherBCBS MA
MA468195OtherTUFTS HEALTH PLAN
MA0198676Medicaid
MA468195OtherTUFTS HEALTH PLAN
H04713Medicare UPIN