Basic Information
| Provider Information | |||||||||
| NPI: | 1114925211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIPP | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386368 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BROOKLINE PL | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024457224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177390245 | ||||||||
| FaxNumber: | 6177386703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 77466 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207VM0101X | 77466 | MA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207V00000X | 77466 | MA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3116689 | 05 | MA | MEDICAID |