Provider Demographics
NPI:1740751981
Name:GREGG L MASSANELLI MDPA
Entity Type:Organization
Organization Name:GREGG L MASSANELLI MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:L
Authorized Official - Last Name:MASSANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-862-1144
Mailing Address - Street 1:2700 VINE ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-6700
Mailing Address - Country:US
Mailing Address - Phone:870-862-1144
Mailing Address - Fax:870-881-8154
Practice Address - Street 1:2700 VINE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6700
Practice Address - Country:US
Practice Address - Phone:870-862-1144
Practice Address - Fax:870-881-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty