Healthcare Provider Details

I. General information

NPI: 1063629129
Provider Name (Legal Business Name): CONCILIO PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD RIVER RD SUITE 203
LINCOLN RI
02865-1161
US

IV. Provider business mailing address

132 OLD RIVER RD SUITE 203
LINCOLN RI
02865-1161
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD08172
License Number StateRI

VIII. Authorized Official

Name: MRS. AMALIA CONCILIO
Title or Position: MANAGER
Credential:
Phone: 401-334-2949