MEDICARE: MARY E. DOHERTY NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	105977	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NP3038	OTHER	MA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1578540589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY E. DOHERTY NP

Provider Business Mailing Address
First Line	:	1221 MAIN ST
Second Line	:
City	:	SOUTH WEYMOUTH
State	:	MA
Zip	:	02190-1561
Country	:	US
Telephone Number	:	781-340-1702
Fax Number	:	781-340-0931

Provider Business Practice Location Address
First Line	:	1221 MAIN ST
Second Line	:
City	:	SOUTH WEYMOUTH
State	:	MA
Zip	:	02190-1561
Country	:	US
Telephone Number	:	781-340-1702
Fax Number	:	781-340-0931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	10/22/2007

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