1811074909 NPI number — DR. PHILEMON T MARVELL M.D.

Table of content: DR. PHILEMON T MARVELL M.D. (NPI 1811074909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811074909 NPI number — DR. PHILEMON T MARVELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARVELL
Provider First Name:
PHILEMON
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1811074909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
552 W MAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE COMPTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02837-1123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-592-0137
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 WAKE ROBIN RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02865-4295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-475-7650
Provider Business Practice Location Address Fax Number:
401-475-7655
Provider Enumeration Date:
11/01/2006

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: 207Q00000X , with the licence number:  41799 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: MD05394 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0134546 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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