Basic Information
| Provider Information | |||||||||
| NPI: | 1558351676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIZZO | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 490 BOSTON POST RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SUDBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017763367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784436086 | ||||||||
| FaxNumber: | 9782877856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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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 | 56243 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1211382 | 05 | MA | MEDICAID |