1780705707 NPI number — JACK R BEVIVINO MD

Table of content: JACK R BEVIVINO MD (NPI 1780705707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780705707 NPI number — JACK R BEVIVINO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVIVINO
Provider First Name:
JACK
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1780705707
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:
120 DUDLEY STREET
Provider Second Line Business Mailing Address:
SUITE #201
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-2431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-521-9290
Provider Business Mailing Address Fax Number:
401-521-9297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 DUDLEY STREET
Provider Second Line Business Practice Location Address:
SUITE #201
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02905-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-521-9290
Provider Business Practice Location Address Fax Number:
401-521-9297
Provider Enumeration Date:
04/03/2007

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: 208200000X , with the licence number:  RIMD05259 , 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: 1300124 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9002112 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21126 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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