Healthcare Provider Details

I. General information

NPI: 1174585723
Provider Name (Legal Business Name): GERARDO CONCILIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD RIVER RD SUITE203
LINCOLN RI
02865-1161
US

IV. Provider business mailing address

132 OLD RIVER RD SUITE203
LINCOLN RI
02865-1397
US

V. Phone/Fax

Practice location:
  • Phone: 401-334-2949
  • Fax: 401-334-0867
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD08172
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: