1700843661 NPI number — RICHARD G GILLERMAN MD

Table of content: RICHARD G GILLERMAN MD (NPI 1700843661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700843661 NPI number — RICHARD G GILLERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLERMAN
Provider First Name:
RICHARD
Provider Middle Name:
G
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:
1700843661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ONE VIRGINIA AVENUE
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-490-0916
Provider Business Mailing Address Fax Number:
401-490-0979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
593 EDDY STREET
Provider Second Line Business Practice Location Address:
DAVOL 129
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-444-4933
Provider Business Practice Location Address Fax Number:
401-444-5090
Provider Enumeration Date:
04/26/2006

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: 207L00000X , with the licence number:  8572 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: MD08572 , 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: 7003698 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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