Healthcare Provider Details

I. General information

NPI: 1912015033
Provider Name (Legal Business Name): ROBERT G MCRAE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 DUDLEY ST
PROVIDENCE RI
02905-2403
US

IV. Provider business mailing address

118 DUDLEY ST
PROVIDENCE RI
02905-2403
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-2300
  • Fax: 401-272-1302
Mailing address:
  • Phone: 401-274-2300
  • Fax: 401-272-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5604
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: