MEDICARE: KIM MCGILLICUDDY MACIASZEK OD

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	152W00000X	Optometrist	3760	MA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	410046213	OTHER		RAILROAD MEDICARE
13	W17219	OTHER		MEDICARE B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	AA2839	OTHER	HARVARD PILGRIM
3	60892	OTHER	FALLON COMMUNITY HEALTH
4	7252603	OTHER	AETNA US HEALTHCARE
5	042472266015	OTHER	TRICARE CHAMPUS
6	786726	OTHER	MVP HEALTH CARE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	042472266	OTHER	PRIVATE HEALTHCARE
9	042472266	OTHER	THREE RIVERS
10	2212894	OTHER	FIRST HEALTH
11	8974875	OTHER	CIGNA HEALTH PLAN
12	W16304	OTHER	BLUE CARE ELECT

General Provider Information

NPI Number	:	1871577254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM MCGILLICUDDY MACIASZEK OD

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	426 N MAIN ST
Second Line	:
City	:	EAST LONGMEADOW
State	:	MA
Zip	:	01028-1850
Country	:	US
Telephone Number	:	413-525-3010
Fax Number	:	413-525-7667

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	09/16/2024

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