Healthcare Provider Details

I. General information

NPI: 1376679860
Provider Name (Legal Business Name): JEREMY LYLE WARNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD48754
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number48754
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD18301
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: