Basic Information
| Provider Information | |||||||||
| NPI: | 1285959676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACIP RODRIGUEZ | ||||||||
| FirstName: | PERLA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 HARRISON AVE | ||||||||
| Address2: | DOB 503 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 MASSACHUSETTS AVENUE | ||||||||
| Address2: | CROSSTOWN 2 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174147399 | ||||||||
| FaxNumber: | 6174144676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 254670 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 254670 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110102924A | 05 | MA | MEDICAID |