Basic Information
| Provider Information | |||||||||
| NPI: | 1164457099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLKHOVSKY | ||||||||
| FirstName: | ALLA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | 5084603221 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 WORCESTER RD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017015224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088723254 | ||||||||
| FaxNumber: | 5088797910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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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 | 50367 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3038939 | 05 | MA | MEDICAID |