Healthcare Provider Details

I. General information

NPI: 1548205735
Provider Name (Legal Business Name): SHEENAGH BODKIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 WEST RIVER STREET 3RD FLOOR
PROVIDENCE RI
02904
US

IV. Provider business mailing address

146 WEST RIVER STREET 3RD FLOOR
PROVIDENCE RI
02904
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-5700
  • Fax: 401-793-7801
Mailing address:
  • Phone: 401-793-5700
  • Fax: 401-793-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD09915
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD09915
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: