Healthcare Provider Details

I. General information

NPI: 1720089063
Provider Name (Legal Business Name): JOHN MICHAEL TUMOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST SUITE 104
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST SUITE 104
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-0636
  • Fax: 508-764-4219
Mailing address:
  • Phone: 508-765-0636
  • Fax: 508-764-4219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number50918
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: