Provider Demographics
NPI:1225028863
Name:TRUCKSIS, MICHELE (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:TRUCKSIS
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:INFECTIOUS DISEASE ASSOCIATES GRJ 504
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-3812
Practice Address - Fax:617-726-7416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA58871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA058871OtherTUFTS HEALTH PLAN
MA3046788Medicaid
MAJ08862OtherBCBS MA
MAJ08862Medicare ID - Type Unspecified
MA3046788Medicaid