Healthcare Provider Details

I. General information

NPI: 1275546277
Provider Name (Legal Business Name): BRIAN R THEROUX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 S COUNTY TRL STE 101
E GREENWICH RI
02818-5098
US

IV. Provider business mailing address

1672 S COUNTY TRL STE. 301
E GREENWICH RI
02818-5098
US

V. Phone/Fax

Practice location:
  • Phone: 401-885-7546
  • Fax: 401-885-6658
Mailing address:
  • Phone: 401-885-7546
  • Fax: 401-885-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00289
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: