Provider Demographics
NPI:1962476994
Name:FERULLO, SHAWN M (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:FERULLO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:77 MASSACHUSETTS AVE
Mailing Address - Street 2:MASSACHUSETTS INSTITUTE OF TECHNOLOGY, E23-171
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4301
Mailing Address - Country:US
Mailing Address - Phone:617-253-2974
Mailing Address - Fax:617-253-5512
Practice Address - Street 1:25 CARLETON ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1323
Practice Address - Country:US
Practice Address - Phone:617-253-2974
Practice Address - Fax:617-253-5512
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-11-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA219827207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2037106Medicaid
MAI02373Medicare UPIN
MAA36556Medicare ID - Type Unspecified