Basic Information
| Provider Information | |||||||||
| NPI: | 1831129147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSELLO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | PAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 LAKE HARBOR DR | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376152972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234778258 | ||||||||
| FaxNumber: | 5016445818 | ||||||||
| Practice Location | |||||||||
| Address1: | JAMES H. QUILLEN/VAMC | ||||||||
| Address2: | CORNER OF SIDNEY AND LAMONT (JOHNSON CITY) | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376844000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239792734 | ||||||||
| FaxNumber: | 4239792696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208600000X | 08553 | MS | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.