Healthcare Provider Details

I. General information

NPI: 1700843661
Provider Name (Legal Business Name): RICHARD G GILLERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET DAVOL 129
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

ONE VIRGINIA AVENUE SUITE 201
PROVIDENCE RI
02905
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4933
  • Fax: 401-444-5090
Mailing address:
  • Phone: 401-490-0916
  • Fax: 401-490-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number8572
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD08572
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: