Provider Demographics
NPI:1215190087
Name:MOUSSA-PERVANE, RUNNA FAYEZ (MD)
Entity Type:Individual
Prefix:
First Name:RUNNA
Middle Name:FAYEZ
Last Name:MOUSSA-PERVANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 DARTMOUTH ST
Mailing Address - Street 2:INTERNAL MEDICINE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5123
Mailing Address - Country:US
Mailing Address - Phone:617-859-5101
Mailing Address - Fax:617-859-5050
Practice Address - Street 1:165 DARTMOUTH ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5123
Practice Address - Country:US
Practice Address - Phone:617-859-5101
Practice Address - Fax:617-859-5050
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233262207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087154AMedicaid
MA001799001Medicare PIN