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

Table of Contents

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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