Healthcare Provider Details

I. General information

NPI: 1407840903
Provider Name (Legal Business Name): CHARLES JOHN BREX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 VETERANS MEMORIAL PKWY BLDG 4
EAST PROVIDENCE RI
02914-5300
US

IV. Provider business mailing address

10 DAVOL SQ SUITE 400
PROVIDENCE RI
02903-4754
US

V. Phone/Fax

Practice location:
  • Phone: 401-435-3400
  • Fax: 401-435-3586
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD05092
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: