Basic Information
Provider Information | |||||||||
NPI: | 1700859212 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACGILLIVRAY | ||||||||
FirstName: | JANICE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 48 PARTRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | WEST ROXBURY | ||||||||
State: | MA | ||||||||
PostalCode: | 021323010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174692050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7 HAVILAND ST | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021152683 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179276100 | ||||||||
FaxNumber: | 6172473460 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1707 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.