Provider Demographics
NPI:1922454859
Name:IANNAMORELLI, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:IANNAMORELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-475-0831
Practice Address - Fax:508-856-4224
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266760208600000X
PAOS022075208600000X, 2086S0102X
MA2873972086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery