1962695155 NPI number — RICHARD P. IACOBUCCI MD, INC.

Table of content: (NPI 1962695155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962695155 NPI number — RICHARD P. IACOBUCCI MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD P. IACOBUCCI MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962695155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1635 MINERAL SPRING AVENUE
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
NO. PROVIDENCE
Provider Business Mailing Address State Name:
RHODE ISLAND
Provider Business Mailing Address Postal Code:
02904
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
401-353-4936
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 MINERAL SPRING AVE
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
NORTH PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02904-4025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-353-4936
Provider Business Practice Location Address Fax Number:
401-270-3304
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REBELLO
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
401-353-4936

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9002331 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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