Basic Information
| Provider Information | |||||||||
| NPI: | 1992791339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | TRISTA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 BELMONT ST | ||||||||
| Address2: | DEPT OF ORTHOPEDICS | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083348689 | ||||||||
| FaxNumber: | 5083349769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036110768 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 246354 | MA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036110768 | 05 | IL | MEDICAID | 01621490 | 01 | IL | BCBS PROVIDER ID | OTHER | 110087984A | 05 | MA | MEDICAID | 036-110768 | 05 | IL | MEDICAID | 131667300 | 01 | IL | OWCP PROVIDER ID | OTHER | P00146855 | 01 | IL | RAILROAD MEDICARE | OTHER |