Healthcare Provider Details

I. General information

NPI: 1427045905
Provider Name (Legal Business Name): EDWARD MCGOOKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WARREN AVE SUITE 200
EAST PROVIDENCE RI
02914-1430
US

IV. Provider business mailing address

10 DAVOL SQ SUITE 400
PROVIDENCE RI
02903-4754
US

V. Phone/Fax

Practice location:
  • Phone: 401-421-6481
  • Fax: 401-751-8734
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD09577
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: