Basic Information
| Provider Information | |||||||||
| NPI: | 1740519784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERILLA | ||||||||
| FirstName: | MA AMIL | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 HALL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | CRISFIELD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109681200 | ||||||||
| FaxNumber: | 4109683178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2009 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/16/2012 | ||||||||
| NPIReactivationDate: | 08/24/2012 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19495 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 22550 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 29927 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.