Provider Demographics
NPI:1215924634
Name:AVERILL, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:AVERILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-3315
Mailing Address - Country:US
Mailing Address - Phone:413-774-3077
Mailing Address - Fax:413-774-3077
Practice Address - Street 1:474 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-3315
Practice Address - Country:US
Practice Address - Phone:413-774-3077
Practice Address - Fax:413-774-3077
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA41366207N00000X
NH6631207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0161918Medicaid
MA0161918Medicaid
MAF10100Medicare ID - Type Unspecified