Basic Information
| Provider Information | |||||||||
| NPI: | 1891752291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUTHWORTH | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573070896 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127326315 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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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 | 207R00000X | 79458 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3128580 | 05 | MA | MEDICAID |