Healthcare Provider Details

I. General information

NPI: 1811413735
Provider Name (Legal Business Name): JESSE TIRALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 STAFFORD RD
BARSTOW MD
20610
US

IV. Provider business mailing address

2865 HOLLAND CLIFFS RD
HUNTINGTOWN MD
20639-8820
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5400
  • Fax:
Mailing address:
  • Phone: 443-432-8854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: