Basic Information
| Provider Information | |||||||||
| NPI: | 1346336831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 20 RESEARCH PL | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NORTH CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018632412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784596737 | ||||||||
| FaxNumber: | 9784592580 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 RESEARCH PL | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NORTH CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018632412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784596737 | ||||||||
| FaxNumber: | 8558181869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 208339 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0027528 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 693290 | 01 | MA | HARVARD PILGRIM | OTHER | 0177181 | 05 | MA | MEDICAID | 405299 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J25362 | 01 | MA | BLUE CROSS | OTHER | 3670044-002 | 01 | MA | CIGNA | OTHER |