Healthcare Provider Details

I. General information

NPI: 1568590859
Provider Name (Legal Business Name): WILLIAM G LAVELLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF OTOLARYNGOLOGY
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 62 TURNPIKE STATION
SHREWSBURY MA
01545-0062
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-8563
  • Fax:
Mailing address:
  • Phone: 508-334-8815
  • Fax: 508-334-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number33480
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: