Basic Information
| Provider Information | |||||||||
| NPI: | 1508857707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEILSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683150 | ||||||||
| FaxNumber: | 5083683152 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 230 S | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683150 | ||||||||
| FaxNumber: | 5083683152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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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 | 2084N0400X | 74084 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 042472266 | 01 | ONE HEALTH PLAN | OTHER | 5845001 | 01 | AETNA US HEALTHCARE | OTHER | AA3016 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | 29203 | 01 | CHILDRENS MEDICAL SECURIT | OTHER | J14372 | 01 | BLUE CARE ELECT | OTHER | 042472266 | 01 | HEALTHCARE VALUE MANAGEME | OTHER | 9900842 | 01 | FALLON COMMUNITY HEALTH P | OTHER | J14372 | 01 | BLUE SHIELD HMO BLUE | OTHER | J14372 | 01 | BLUE INDEMNITY | OTHER | 130015211 | 01 | RAILROAD MEDICARE | OTHER | J14372 | 01 | MEDICARE B | OTHER | 3118649 | 01 | MEDICAID WELFARE | OTHER | 784035 | 01 | MVP HEALTH CARE | OTHER | 0500193 | 01 | EVERCARE | OTHER | 29203 | 01 | HEALTHY START | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 1700170 | 01 | CIGNA PAL ID | OTHER | 917831 | 01 | FIRST HEALTH | OTHER |