Basic Information
| Provider Information | |||||||||
| NPI: | 1952390007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 69 WILMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021244512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174368968 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2110 DORCHESTER AVE | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172960456 | ||||||||
| FaxNumber: | 6172961655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 53555 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0401251 | 01 | MA | UNITED HEALTHCARE | OTHER | J05571 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 000000020228 | 01 | MA | BOSTON HEALTH NET | OTHER | 709833 | 01 | TUFTS ASSOCIATED HEALTH P | OTHER | 92477 | 01 | AETNA US HEALTHCARE | OTHER | B10127801 | 01 | CIGNA HEALTHCARE | OTHER | 3037444 | 05 | MA | MEDICAID |