Provider Demographics
NPI:1437104270
Name:TOMASELLO, JILL M (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:TOMASELLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5558
Mailing Address - Country:US
Mailing Address - Phone:203-359-8326
Mailing Address - Fax:203-328-2696
Practice Address - Street 1:999 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5546
Practice Address - Country:US
Practice Address - Phone:203-359-8326
Practice Address - Fax:203-328-2696
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02488Medicare ID - Type Unspecified