Provider Demographics
NPI:1801809967
Name:PHILIP J TAVANO MD PC
Entity type:Organization
Organization Name:PHILIP J TAVANO MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-459-2152
Mailing Address - Street 1:20 RESEARCH PL
Mailing Address - Street 2:SUITE 310
Mailing Address - City:N CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01863-2454
Mailing Address - Country:US
Mailing Address - Phone:978-459-2152
Mailing Address - Fax:978-452-7285
Practice Address - Street 1:20 RESEARCH PL
Practice Address - Street 2:SUITE 310
Practice Address - City:N CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-2454
Practice Address - Country:US
Practice Address - Phone:978-459-2152
Practice Address - Fax:978-452-7285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPHM13259OtherBLUE SHIELD OF MA
1043245145OtherNPI
MA00-00760OtherEVERCARE
1205861390OtherNPI
MA702916OtherTUFTS HEALTH PLAN
MA9719741Medicaid
1710919238OtherNPI
G91515Medicare UPIN
1205861390OtherNPI
MAPHM13259OtherBLUE SHIELD OF MA
MA9719741Medicaid
A38166Medicare UPIN
MAC0470Medicare PIN
1710919238OtherNPI
M13259Medicare ID - Type Unspecified