Provider Demographics
NPI:1508319682
Name:EBRILLE, ELISA
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:EBRILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 PILGRIM RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5324
Mailing Address - Country:US
Mailing Address - Phone:617-997-2967
Mailing Address - Fax:
Practice Address - Street 1:185 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5324
Practice Address - Country:US
Practice Address - Phone:617-997-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA268565282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital