Provider Demographics
NPI:1841255486
Name:CARR, PHYLLIS L (MD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:L
Last Name:CARR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SHAPIRO 5, SUITE A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-7428
Practice Address - Fax:617-638-7472
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA47799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2083213Medicaid
MA2083213Medicaid
MAB74120Medicare UPIN