Healthcare Provider Details

I. General information

NPI: 1548245962
Provider Name (Legal Business Name): FADI MANSOURATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

886 MINERAL SPRING AVE
PAWTUCKET RI
02860-3322
US

IV. Provider business mailing address

886 MINERAL SPRING AVE
PAWTUCKET RI
02860-3322
US

V. Phone/Fax

Practice location:
  • Phone: 401-475-3063
  • Fax: 401-475-0593
Mailing address:
  • Phone: 401-475-3063
  • Fax: 401-475-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD09843
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: