Healthcare Provider Details

I. General information

NPI: 1073511218
Provider Name (Legal Business Name): EDWARD J. MARCACCIO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST SUITE 470
PROVIDENCE RI
02905-3236
US

IV. Provider business mailing address

PO BOX 16149
RUMFORD RI
02916-0697
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-8318
  • Fax: 401-868-2307
Mailing address:
  • Phone: 401-453-9625
  • Fax: 401-435-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD08399
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: