Healthcare Provider Details

I. General information

NPI: 1982960696
Provider Name (Legal Business Name): JAMES M CERULLO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

125 WHIPPLE STREET 3RD FLOOR
PROVIDENCE RI
02908-3258
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3000
  • Fax:
Mailing address:
  • Phone: 401-854-2504
  • Fax: 401-427-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4793
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00645
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: