Basic Information
| Provider Information | |||||||||
| NPI: | 1417414624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIERRE | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | ROODLINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 109 OAK ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176585611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 109 OAK ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176585611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2019 | ||||||||
| LastUpdateDate: | 02/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 100028934147 | 01 | MA | MASS HEALTH | OTHER |