Healthcare Provider Details

I. General information

NPI: 1073627600
Provider Name (Legal Business Name): ROENGSAK TULATHIMUTTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 BEECH ST ANESTHESIA DEPT
HOLYOKE MA
01040-2223
US

IV. Provider business mailing address

22 S SYCAMORE KNLS
SOUTH HADLEY MA
01075-1112
US

V. Phone/Fax

Practice location:
  • Phone: 413-534-2845
  • Fax:
Mailing address:
  • Phone: 413-534-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number47834
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: