Healthcare Provider Details
I. General information
NPI: 1568458479
Provider Name (Legal Business Name): DR. GARY JOHN NIELAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 09/26/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
2207 BOSTON RD
WILBRAHAM MA
01095-1155
US
IV. Provider business mailing address
2207 BOSTON RD
WILBRAHAM MA
01095-1155
US
V. Phone/Fax
- Phone: 413-599-1201
- Fax: 413-596-2940
- Phone: 413-599-1201
- Fax: 413-596-2940
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2080A0000X |
| Taxonomy | Pediatric Adolescent Medicine Physician |
| License Number | 155058 |
| License Number State | MA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 2017078 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | AETNA/USHC |
| # 2 | |
| Identifier | 155058 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | MA LICENSE |
| # 3 | |
| Identifier | 23378 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | HEALTH NEW ENGLAND |
| # 4 | |
| Identifier | 28036 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | CHILDRENS MEDICAL SECURIT |
| # 5 | |
| Identifier | 353451 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | HEALTHSOURCE MA NH |
| # 6 | |
| Identifier | J18133 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | BCBS |
| # 7 | |
| Identifier | 102170 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | CIGNA |
| # 8 | |
| Identifier | 1550588404 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | CONNECTICARE |
| # 9 | |
| Identifier | 3182916 |
| Identifier Type | MEDICAID |
| Identifier State | MA |
| Identifier Issuer | |
| # 10 | |
| Identifier | 1204585 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | UNITED HEALTHCARE |
| # 11 | |
| Identifier | 155058 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | TUFTS |
| # 12 | |
| Identifier | 975887 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | NETWORK HEALTH |
| # 13 | |
| Identifier | 010155058MA01 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | ANTHEM BCBS |
| # 14 | |
| Identifier | 201928 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | HARVARD PILGRIM |
| # 15 | |
| Identifier | 000000008141 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | BOSTON MED CENTER HEALTH |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
