Basic Information
| Provider Information | |||||||||
| NPI: | 1215993910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANDELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | MASS GENERAL PHYSICIAN ORGANIZATION | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175732621 | ||||||||
| FaxNumber: | 6175732769 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 NASHUA ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175732200 | ||||||||
| FaxNumber: | 6175732099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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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 | 208100000X | 75747 | MA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 3109500 | 05 | MA | MEDICAID | 075747 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J13759 | 01 | MA | BCBS MA | OTHER |