Healthcare Provider Details

I. General information

NPI: 1083633580
Provider Name (Legal Business Name): MICHAEL J.F. IANNESSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 STATE RD
PLYMOUTH MA
02360-5133
US

IV. Provider business mailing address

40 CHESTNUT ST APT. #2
CHARLESTOWN MA
02129-3436
US

V. Phone/Fax

Practice location:
  • Phone: 508-224-7701
  • Fax:
Mailing address:
  • Phone: 781-254-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number52862
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number52862
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: