Healthcare Provider Details

I. General information

NPI: 1427035302
Provider Name (Legal Business Name): SUSAN P PERRINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 HARRISON AVE MOAKLEY, 3RD FLOOR
BOSTON MA
02118-2905
US

IV. Provider business mailing address

720 HARRISON AVE DOB5
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6428
  • Fax: 617-638-5756
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number42952
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42952
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number42952
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: