Healthcare Provider Details

I. General information

NPI: 1972869428
Provider Name (Legal Business Name): JERALD I KUPPERBERG MD,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOWARD HILL RD
FOSTER RI
02825-1220
US

IV. Provider business mailing address

54 HOWARD HILL RD
FOSTER RI
02825-1220
US

V. Phone/Fax

Practice location:
  • Phone: 401-397-4638
  • Fax:
Mailing address:
  • Phone: 401-397-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRI 05404
License Number StateRI

VIII. Authorized Official

Name: JERALD I KUPPERBERG
Title or Position: PRESIDENT
Credential: MD
Phone: 401-397-4638