Basic Information
| Provider Information | |||||||||
| NPI: | 1255389151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICARIELLO | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 1153 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179834410 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 42553 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 701907 | 01 | MA | TUFTS | OTHER | 0004084 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 0106534 | 05 | MA | MEDICAID | E05236 | 01 | MA | BLUE CROSS | OTHER | 60492 | 01 | MA | HARVARD PILGRIM | OTHER |