Healthcare Provider Details

I. General information

NPI: 1215502877
Provider Name (Legal Business Name): TUCKER CALLANAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 200
PROVIDENCE RI
02905-3252
US

IV. Provider business mailing address

1 KETTLE POINT AVE
EAST PROVIDENCE RI
02914-5375
US

V. Phone/Fax

Practice location:
  • Phone: 401-443-4205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD21363
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: