Basic Information
| Provider Information | |||||||||
| NPI: | 1114285905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RULLAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021434311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173947703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 119 WINDSOR ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021393647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176653600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 265139 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 314000000X | 265139 | MA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 207RG0300X | 265139 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.