Healthcare Provider Details

I. General information

NPI: 1417126087
Provider Name (Legal Business Name): MICHAEL E TORTORELLO I PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SOUTH RD DERMATOLOGY
FARMINGTON CT
06032-2410
US

IV. Provider business mailing address

263 FARMINGTON AVE PROVIDER ENROLLMENT
FARMINGTON CT
06030-2212
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4600
  • Fax: 860-679-1248
Mailing address:
  • Phone: 860-679-7503
  • Fax: 860-679-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000653
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000653
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: