1720068307 NPI number — DONNELLA SIMONE COMEAU MD PHD

Table of content: LAUREN LECLAIRE BSN,RN (NPI 1114764131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720068307 NPI number — DONNELLA SIMONE COMEAU MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COMEAU
Provider First Name:
DONNELLA
Provider Middle Name:
SIMONE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN
Provider Other First Name:
DONELLA
Provider Other Middle Name:
SIMONE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720068307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 ELMGROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02906-4233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-962-8621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 BROAD ST
Provider Second Line Business Practice Location Address:
ADVANCED RADIOLOGY
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02864-6919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-725-6736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  223820 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD12003 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J29652 . This is a "BLOE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2112710 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 294444 . This is a "TUFTS HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".