Basic Information
| Provider Information | |||||||||
| NPI: | 1578694980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOTH | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NURSE PRACTITIONER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 143 LONGWATER DRIVE | ||||||||
| Address2: | SOUTH SHORE MEDICAL CENTER | ||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | SOUTH SHORE MEDICAL CENTER | ||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 262089 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 042297845 | 01 | PHCS/MULTI-PLAN | OTHER | 000065002 | 01 | MA | MEDICARE | OTHER | 110085470A | 05 | MA | MEDICAID | SS0070 | 01 | MA | BCBSMA | OTHER | 042297845 | 01 | TRICARD | OTHER | 1578694980 | 01 | FALLON HEALTH CARE | OTHER |