Basic Information
| Provider Information | |||||||||
| NPI: | 1558449744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLVIN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | MASS GENERAL PHYSICIAN ORGANIZATION | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177240287 | ||||||||
| FaxNumber: | 6177262894 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT STREET | ||||||||
| Address2: | COX 5 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177263812 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| 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 | 207R00000X | 157080 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 799140 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 3200621 | 05 | MA | MEDICAID | J21718 | 01 | MA | BCBS MA | OTHER |