Healthcare Provider Details

I. General information

NPI: 1780625715
Provider Name (Legal Business Name): MICHAEL JOSEPH TULLOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 LEROY ST
POTSDAM NY
13676-1786
US

IV. Provider business mailing address

50 LEROY ST
POTSDAM NY
13676-1786
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-3300
  • Fax:
Mailing address:
  • Phone: 315-265-3300
  • Fax: 315-261-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number175113
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number175113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: