Provider Demographics
NPI:1285262378
Name:PICARD-FRASER, PHILIP A (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:PICARD-FRASER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:ALEXANDRE
Other - Last Name:PICARD-FRASER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-6087
Practice Address - Fax:774-442-6060
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020178207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110164510AMedicaid