Provider Demographics
NPI:1891751855
Name:CLARKE, MAUREEN P (MD)
Entity Type:Individual
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First Name:MAUREEN
Middle Name:P
Last Name:CLARKE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2012-01-05
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Provider Licenses
StateLicense IDTaxonomies
MA489122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0027086OtherNEIGHBORHOOD HEALTH
MA6170277Medicaid
MAP00074198OtherP00074198
MA048912OtherTUFTS HEALTH PLAN
MA1501845-003OtherCIGNA
MA1501845-003OtherHEALTHSOURCE
MAJ02335OtherBLUE CROSS BLUE SHIELD
MAB74242Medicare UPIN
MA6170277Medicaid