Basic Information
| Provider Information | |||||||||
| NPI: | 1912978461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9135 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556793 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 01/18/2010 | ||||||||
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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 | 54222 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 54222 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000033748 | 01 | MA | BMC HEALTHNET | OTHER | 3001385 | 05 | MA | MEDICAID | J04943 | 01 | MA | BCBS MA | OTHER | J04943 | 01 | MA | BLUE CARE ELECT | OTHER | J04943 | 01 | MA | HMO BLUE | OTHER |