Healthcare Provider Details

I. General information

NPI: 1740227198
Provider Name (Legal Business Name): RANDALL LEE UPDEGROVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 S COUNTY TRL SUITE 510
EAST GREENWICH RI
02818-5081
US

IV. Provider business mailing address

2 DUDLEY ST SUITE
PROVIDENCE RI
02905-3236
US

V. Phone/Fax

Practice location:
  • Phone: 401-884-9605
  • Fax: 401-884-9882
Mailing address:
  • Phone: 401-884-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8772
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number08772
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: