Basic Information
| Provider Information | |||||||||
| NPI: | 1134180425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | MARTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHARLTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015071315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082481745 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 155910 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 155190 | 01 | TUFTS HEALTH PLAN | OTHER | 31001 | 01 | CHILDRENS MEDICAL SECURIT | OTHER | 5478684 | 01 | AETNA US HEALTHCARE | OTHER | 9077680 | 01 | CIGNA HEALTH PLAN | OTHER | 3183475 | 01 | MEDICAID WELFARE | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 31001 | 01 | HEALTHY START | OTHER | J19558 | 01 | BLUE CARE ELECT | OTHER | J19558 | 01 | BLUE SHIELD INDEMNITY | OTHER | 042472266 | 01 | ONE HEALTH PLAN | OTHER | 42367 | 01 | FALLON COMMUNITY HEALTH P | OTHER | 3183475 | 05 | MA | MEDICAID | 71937 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | 786721 | 01 | MVP HEALTH CARE | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 2031301 | 01 | FIRST HEALTH | OTHER | J19558 | 01 | BLUE SHIELD HMO BLUE | OTHER |