Healthcare Provider Details

I. General information

NPI: 1154716546
Provider Name (Legal Business Name): GALINA GRIGORIEV LAGOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET APC MAIN
PROVIDENCE RI
02903
US

IV. Provider business mailing address

593 EDDY ST RM 302
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5435
  • Fax: 401-444-8301
Mailing address:
  • Phone: 401-444-6654
  • Fax: 401-444-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD17380
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: