Basic Information
| Provider Information | |||||||||
| NPI: | 1134133135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATNICK | ||||||||
| FirstName: | MURRAY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174212508 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174211000 | ||||||||
| FaxNumber: | 6174216084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085N0904X | 29482 | MA | X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 29482 | MA | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | R230 | 01 | MA | HARVARD PILGRIM | OTHER | 029482 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0022310 | 01 | MD | NEIGHBORHOOD HEALTH PLAN | OTHER | F19010 | 01 | MA | BLUE CROSS | OTHER | 2026147 | 05 | MA | MEDICAID | 1555154-003 | 01 | MA | CIGNA | OTHER | 1555154-003 | 01 | MD | HEALTHSOURCE | OTHER |