Healthcare Provider Details

I. General information

NPI: 1366402018
Provider Name (Legal Business Name): Drs Concannon & Vitale LLC
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: DRS. CONCANNON & VITALE, LLC

II. Dates (important events)

Enumeration Date: 03/26/2006
Last Update Date: 12/16/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address




US

IV. Provider business mailing address

1145 Reservoir Ave Suite 124
Cranston RI
02920
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 4019437337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRI 12102
License Number StateRI
# 2
Primary Taxonomy
Taxonomy Code
TaxonomyPediatrics Physician
License NumberDO 00357
License Number StateRI
# 3
Primary Taxonomy
Taxonomy Code
TaxonomyFamily Nurse Practitioner
License NumberAPRN02559
License Number StateRI

VIII. Authorized Official

Name: DR. JOHN E CONCANNON
Title or Position: SENIOR PARTNER
Credential: DO
Phone: 401-943-7337