MARIO GERARD MASSULLO (NPI# 1043228158) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1043228158 |
| Entity Type | Individual |
| Full Name | MARIO GERARD MASSULLO |
| Credential | D.O. |
| Practice Address |
1710 W. Court St. Kankakee IL 60901 |
| Mailing Address |
1710 W Court St Kankakee IL 60901-3160 |
| Practice Telephone | 8159363200 |
| Practice Fax Number | 8159363203 |
| Mailing Telephone | 8159363200 |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2019-07-08 |
| Gender Code | M |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207R00000X | Internal Medicine | 036082059 | IL | Allopathic & Osteopathic Physicians |
| Y | 207RC0000X |
Internal Medicine Specialization: Cardiovascular Disease |
036082059 | IL | Allopathic & Osteopathic Physicians |
| N | 207RI0011X |
Internal Medicine Specialization: Interventional Cardiology |
036082059 | IL | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | 036082059 | 05 |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 100 Provena Way Ste C, Bourbonnais, IL 609144798 | 8159363200 | 8159363203 |
| Street Address |
1710 W. COURT ST. |
| City | KANKAKEE |
| State | IL |
| Zip Code | 60901 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1558978841 | William Mitsos Dds | Dentist | 1291 S. 7th Ave, Kankakee, IL 60901 | 2020-09-30 |
| 1922653682 | Jody Mcguyer, Lcpc, Cadc Counseling Services, LLC | Counselor | 315 W. Court St., Kankakee, IL 60901 | 2019-08-08 |
| 1700346327 | Sarah Elizabeth Toma | Speech-Language Pathologist | 200 E Court St #708, Kankakee, IL 60901 | 2019-03-20 |
| 1710473160 | Small Talk Speech Services, LLC | Clinic/Center | 1439 W Vanmeter St, Kankakee, IL 60901 | 2018-07-09 |
| 1124538004 | Amy J Green | Physical Therapist | 350 N. Wall Street, Kankakee, IL 60901 | 2017-10-05 |
| 1013457514 | Elizabeth Ann Smith | Registered Nurse | 292 Charlton Lane, Kankakee, IL 60901 | 2017-03-02 |
| 1861931461 | Stacey E. Brown | Nurse Practitioner | 207 N. Schuyler Ave., Kankakee, IL 60901 | 2017-02-15 |
| 1417352105 | Provider Healthcare Services, Inc | Home Health | 555 South Schuyler, Suite 275, Kankakee, IL 60901 | 2014-10-24 |
| 1265850655 | Ronald George Testa | Dentist | 202 N. Schuyler Ave, Kankakee, IL 60901 | 2014-04-02 |
| 1245587898 | Mary Beth Wertz | Registered Nurse | 100 N Jeffery Street, Kankakee, IL 60901 | 2012-08-13 |
| Find all providers in zip 60901 | ||||
| Taxonomy Code | 207RC0000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Internal Medicine |
| Specialization | Cardiovascular Disease |
| An internist who specializes in diseases of the heart and blood vessels and manages complex cardiac conditions such as heart attacks and life-threatening, abnormal heartbeat rhythms. |
| Notes: Source: American Osteopathic Board of Internal Medicine, 2008 [7/1/2008: added definition, added source; 7/1/2011: modified source] - Additional Resources: American Board of Internal Medicine, http://www.abim.org/. American Osteopathic Board of Internal Medicine, https://www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Internal Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Internal Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1124314349 | Gaurang Gujarathi | Internal Medicine | 1710 W Court St, Kankakee, IL 60901 | 2011-06-27 |
| 1487679205 | Vijay M Haryani | Internal Medicine | 500 N Wall St Ste C100, Kankakee, IL 60901-2942 | 2006-07-13 |
| 1316289077 | Tarun Jain | Internal Medicine | 500 N Wall St Ste C100, Kankakee, IL 60901-2942 | 2013-03-20 |
| 1588911333 | Shiva Prasad Shashidharan | Internal Medicine | 500 N Wall St, Kankakee, IL 60901 | 2012-08-11 |
| 1336339381 | Abhimanyu Beri | Internal Medicine | 500 N Wall St, Kankakee, IL 60901-2942 | 2007-07-26 |
| 1447454657 | Advanced Cardiovascular Services | Internal Medicine | 455 W. Court St., Suite 202, Kankakee, IL 60441 | 2007-06-12 |
| 1881729853 | Philip G Hays Md Sc | Internal Medicine | 400 N Wall St Ste 303, Kankakee, IL 60901-2964 | 2007-02-22 |
| 1013099225 | Vijay M. Haryani, Md, Sc | Internal Medicine | 375 N Wall St, Suite 310, Kankakee, IL 60901-3483 | 2006-10-19 |
| 1275540536 | Philip G Hays | Internal Medicine | 400 N Wall St Ste 303, Kankakee, IL 60901-2964 | 2006-08-01 |
| 1013962182 | Lynn G Brown | Internal Medicine | 500 N Wall St, Kankakee, IL 60901-2942 | 2006-05-24 |
| Find all providers in KANKAKEE | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.