Provider Demographics
NPI:1659786051
Name:LI, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LI
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 1:1 NASHUA STREET
Mailing Address - Street 2:1410
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:718-433-7468
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100561300Medicaid