Basic Information
| Provider Information | |||||||||
| NPI: | 1386684439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELLAVALLA | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59 PAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522200 | ||||||||
| FaxNumber: | 6033265832 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 PAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522200 | ||||||||
| FaxNumber: | 6033265832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MI43083768 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0012X | 15057 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | JD083768 | 01 | MI | BLUECROSS STATE ID | OTHER | 0C16002 | 01 | MI | MEDICARE GROUP | OTHER | 104652714 | 05 | MI | MEDICAID | 0829560001 | 01 | MI | MEDICARE DME | OTHER |