Healthcare Provider Details

I. General information

NPI: 1427016658
Provider Name (Legal Business Name): ELIZABETH M RAYNOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE TCC 810
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE TCC 810
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-8130
  • Fax: 617-667-3175
Mailing address:
  • Phone: 617-667-8130
  • Fax: 617-667-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number74741
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number74741
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: