Provider Demographics
NPI:1588763908
Name:FRY, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:FRY
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 1:40 2ND AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1132
Mailing Address - Country:US
Mailing Address - Phone:781-487-4350
Mailing Address - Fax:781-487-4351
Practice Address - Street 1:40 2ND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1132
Practice Address - Country:US
Practice Address - Phone:781-487-4350
Practice Address - Fax:781-487-4351
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2014483Medicaid
MAH85779Medicare UPIN
MAA35448Medicare PIN
MA2014483Medicaid