Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 270618 | MA |
NPI | 1124007109 |
---|---|
Provider Name | Eric James Nilles |
First Address | Lexington, MA 02420-3433 |
Second Address | Boston, MA 02115-6106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2006 |
Last Update Date | 29/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0443473 | (05) | IA |
36963 | WELLMARK BCBS (01) | IA |
E15702 | (02) |