Healthcare Provider Details

I. General information

NPI: 1073875951
Provider Name (Legal Business Name): BRIAN CORMAC MAC GRORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET APC 5
PROVIDENCE RI
02903
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6440
  • Fax: 401-444-6858
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD15639
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: