Healthcare Provider Details

I. General information

NPI: 1740547405
Provider Name (Legal Business Name): AMY MARIE MASELLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PLAIN ST STE 501
PROVIDENCE RI
02905-3243
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5495
  • Fax: 401-444-5716
Mailing address:
  • Phone: 401-444-6779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number270232
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD17856
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: