Healthcare Provider Details

I. General information

NPI: 1770770547
Provider Name (Legal Business Name): SURGICAL & COSMETIC DERMATOLOGY OF RHODE ISLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RANDALL SQ SUITE 306
PROVIDENCE RI
02904-2709
US

IV. Provider business mailing address

1 RANDALL SQ SUITE 306
PROVIDENCE RI
02904-2709
US

V. Phone/Fax

Practice location:
  • Phone: 401-751-7546
  • Fax: 401-751-6888
Mailing address:
  • Phone: 401-751-7546
  • Fax: 401-751-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD10753
License Number StateRI

VIII. Authorized Official

Name: DR. MARINA KUPERMAN-BEADE
Title or Position: OWNER
Credential: M.D.
Phone: 401-751-7546