Healthcare Provider Details

I. General information

NPI: 1205259793
Provider Name (Legal Business Name): KEVIN E BAILL, MD AND ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 BLACKSTONE BLVD
PROVIDENCE RI
02906-4800
US

IV. Provider business mailing address

PO BOX 603198
PROVIDENCE RI
02906-0198
US

V. Phone/Fax

Practice location:
  • Phone: 917-447-2138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number12179
License Number StateRI

VIII. Authorized Official

Name: DR. KEVIN ELLIOT BAILL
Title or Position: PRESIDENT
Credential: MD
Phone: 917-447-2138