Basic Information
| Provider Information | |||||||||
| NPI: | 1417116054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MAIREAD | ||||||||
| MiddleName: | RYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DONAHUE | ||||||||
| OtherFirstName: | MAIREAD | ||||||||
| OtherMiddleName: | RYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | |||||||||
| City: | S WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021902432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816248000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 246120 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 04-2297845 | 01 | TRICARE | OTHER | AA436677 | 01 | MA | HARVARD PILGRIM | OTHER | 3975418 | 01 | CIGNA | OTHER | 1417116054 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 04-2297845 | 01 | UNITED HEALTH CARE | OTHER | 04-2297845 | 01 | MULTI-PLAN | OTHER | 9984652 | 01 | AETNA | OTHER | J48728 | 01 | MA | BCBSMA | OTHER | 1417116054 | 01 | FALLON COMMUNITY HEALTH PLAN | OTHER | 04-2297845 | 01 | HCVM | OTHER |