Healthcare Provider Details

I. General information

NPI: 1245256528
Provider Name (Legal Business Name): NATHANIEL JOSEF JELLINEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 S COUNTY TRL SUITE 101
EAST GREENWICH RI
02818-5098
US

IV. Provider business mailing address

1672 S COUNTY TRL SUITE 101
EAST GREENWICH RI
02818-5098
US

V. Phone/Fax

Practice location:
  • Phone: 404-885-6647
  • Fax: 401-885-6639
Mailing address:
  • Phone: 404-885-6647
  • Fax: 401-885-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11514
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number11514
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: