Healthcare Provider Details

I. General information

NPI: 1154376697
Provider Name (Legal Business Name): MS. MARYELLEN DOHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 N MAIN ST
ATTLEBORO MA
02703-1518
US

IV. Provider business mailing address

661 ASH ST
BROCKTON MA
02301-5754
US

V. Phone/Fax

Practice location:
  • Phone: 508-222-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number120183
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: