Healthcare Provider Details

I. General information

NPI: 1073864591
Provider Name (Legal Business Name): PEDIATRIC ENDOCRINOLOGY OF RHODE ISLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOCKANOSSET CROSS ROAD SUITE 318
CRANSTON RI
02920
US

IV. Provider business mailing address

50 AMARAL ST
EAST PROVIDENCE RI
02915-2205
US

V. Phone/Fax

Practice location:
  • Phone: 401-434-2058
  • Fax: 401-633-6854
Mailing address:
  • Phone: 401-434-2058
  • Fax: 401-633-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number11312
License Number StateRI

VIII. Authorized Official

Name: REBECCA MCEACHERN
Title or Position: SOLE OWNER/ MEDICAL DIRECTOR
Credential: MD
Phone: 401-419-8091