Basic Information
| Provider Information | |||||||||
| NPI: | 1891751855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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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: | 04/26/2006 | ||||||||
| LastUpdateDate: | 01/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 48912 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0027086 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 6170277 | 05 | MA | MEDICAID | P00074198 | 01 | MA | P00074198 | OTHER | 048912 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 1501845-003 | 01 | MA | CIGNA | OTHER | 1501845-003 | 01 | MA | HEALTHSOURCE | OTHER | J02335 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |