Provider Demographics
NPI:1275654428
Name:FITZGERALD, MARYELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:FITZGERALD
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 1:10 CARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2351
Mailing Address - Country:US
Mailing Address - Phone:617-782-6872
Mailing Address - Fax:
Practice Address - Street 1:77 WARREN ST
Practice Address - Street 2:BUILDING# 2, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-782-6872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine