Healthcare Provider Details

I. General information

NPI: 1780686352
Provider Name (Legal Business Name): SAM C TUMMINELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SERGEANT PRENTISS DR
NATCHEZ MS
39120-4727
US

IV. Provider business mailing address

19 SERGEANT PRENTISS DR
NATCHEZ MS
39120-4727
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-8437
  • Fax: 601-442-8442
Mailing address:
  • Phone: 601-442-8437
  • Fax: 601-442-8442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11638
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number11638
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: