MEDICARE: DR. MARY-HELENE A MASSULLO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	34004036	OH
2	208D00000X	General Practice Physician	34004036	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649348343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY-HELENE A MASSULLO DO

Provider Business Mailing Address
First Line	:	501 VAN BUREN ST
Second Line	:	SUITE 206
City	:	FOSTORIA
State	:	OH
Zip	:	44830-1534
Country	:	US
Telephone Number	:	419-436-1035
Fax Number	:	419-436-0765

Provider Business Practice Location Address
First Line	:	501 VAN BUREN ST
Second Line	:	SUITE 206
City	:	FOSTORIA
State	:	OH
Zip	:	44830-1534
Country	:	US
Telephone Number	:	419-436-1035
Fax Number	:	419-436-0765

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	05/19/2015

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