Provider Demographics
NPI:1992791339
Name:BROWN, TRISTA A (MD)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:A
Last Name:BROWN
Suffix:
Gender:F
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: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 1:119 BELMONT ST
Practice Address - Street 2:DEPT OF ORTHOPEDICS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-8689
Practice Address - Fax:508-334-9769
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110768208100000X
MA246354208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110768Medicaid
IL01621490OtherBCBS PROVIDER ID
MA110087984AMedicaid
IL036-110768Medicaid
IL131667300OtherOWCP PROVIDER ID
ILP00146855OtherRAILROAD MEDICARE
IL036-110768Medicaid
ILK08997Medicare PIN
IL01621490OtherBCBS PROVIDER ID
IL131667300OtherOWCP PROVIDER ID