Healthcare Provider Details

I. General information

NPI: 1134482375
Provider Name (Legal Business Name): RYAN TOURTELLOT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL CENTER DRIVE, SUITE 163 UMDNJ-SOM, JOANN KAISER-SMITH, PROGRAM DIRECTOR
STRATFORD NJ
08084
US

IV. Provider business mailing address

915 STONE RD
LAUREL SPRINGS NJ
08021-3033
US

V. Phone/Fax

Practice location:
  • Phone: 856-677-6708
  • Fax: 856-566-6222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: