Healthcare Provider Details

I. General information

NPI: 1043228158
Provider Name (Legal Business Name): MARIO GERARD MASSULLO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W. COURT ST.
KANKAKEE IL
60901
US

IV. Provider business mailing address

1710 W COURT ST
KANKAKEE IL
60901-3160
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-3200
  • Fax: 815-936-3203
Mailing address:
  • Phone: 815-936-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036082059
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036082059
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036082059
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: