Healthcare Provider Details

I. General information

NPI: 1114900057
Provider Name (Legal Business Name): NICHOLAS M TSANOTELIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 BEDFORD STREET
WHITMAN MA
02382-0000
US

IV. Provider business mailing address

312 BEDFORD ST
WHITMAN MA
02382-1859
US

V. Phone/Fax

Practice location:
  • Phone: 781-792-6000
  • Fax: 781-792-6165
Mailing address:
  • Phone: 781-792-6000
  • Fax: 781-792-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52667
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: