Basic Information
| Provider Information | |||||||||
| NPI: | 1639112022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GLYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | LAHEY CLINIC | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817447000 | ||||||||
| FaxNumber: | 7817447516 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 S BEDFORD ST STE 202E | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018035141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817447000 | ||||||||
| FaxNumber: | 7817447516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | 238648 | MA | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 207R00000X | 238648 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110082094A | 05 | MA | MEDICAID |