Healthcare Provider Details

I. General information

NPI: 1356315576
Provider Name (Legal Business Name): SUSAN P OLIVERIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC 5
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

17 VIRGINIA AVE SUITE 107
PROVIDENCE RI
02905-4406
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4741
  • Fax: 401-444-4445
Mailing address:
  • Phone: 401-784-4923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD12454
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: