Provider Demographics
NPI:1740519784
Name:PERILLA, MA AMIL
Entity type:Individual
Prefix:MRS
First Name:MA AMIL
Middle Name:
Last Name:PERILLA
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 1:201 HALL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CRISFIELD
Mailing Address - State:MD
Mailing Address - Zip Code:21817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 HALL HIGHWAY
Practice Address - Street 2:
Practice Address - City:CRISFIELD
Practice Address - State:MD
Practice Address - Zip Code:21817
Practice Address - Country:US
Practice Address - Phone:410-968-1200
Practice Address - Fax:410-968-3178
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2012-08-27
Deactivation Date:2012-04-16
Deactivation Code:
Reactivation Date:2012-08-24
Provider Licenses
StateLicense IDTaxonomies
PA19495225100000X
MD22550225100000X
NY29927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist