Basic Information
| Provider Information | |||||||||
| NPI: | 1548221476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLIS | ||||||||
| FirstName: | NEAL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | ATTN PHYSICIAN SERVICES WOT 12TH FLOOR | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685529 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088520600 | ||||||||
| FaxNumber: | 5088537149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 46539 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110174997 | 01 | RAILROAD MEDICARE | OTHER | 784131 | 01 | MVP HEALTH CARE | OTHER | N01884 | 01 | BLUE SHIELD HMO BLUE | OTHER | 042472266 | 01 | ONE HEALTH PLAN | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 9900027 | 01 | FALLON COMMUNITY HEALTH P | OTHER | 26805 | 01 | HEALTHY START | OTHER | AA1201 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | N01884 | 01 | BLUE SHIELD INDEMNITY | OTHER | N01884 | 01 | MEDICARE B | OTHER | 0400879 | 01 | EVERCARE | OTHER | 3099385 | 05 | MA | MEDICAID | 5673270 | 01 | CIGNA HEALTH PLAN | OTHER | 917679 | 01 | FIRST HEALTH | OTHER | 3099385 | 01 | MEDICAID WELFARE | OTHER | 7799613 | 01 | AETNA US HEALTHCARE | OTHER | 042472266 | 01 | HEALTHCARE VALUE MANAGMEN | OTHER | N01884 | 01 | BLUE CARE ELECT | OTHER |