Healthcare Provider Details

I. General information

NPI: 1780718056
Provider Name (Legal Business Name): BAYSIDE OB/GYN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PLAIN ST 201
PROVIDENCE RI
02905-3240
US

IV. Provider business mailing address

235 PLAIN ST 201
PROVIDENCE RI
02905-3240
US

V. Phone/Fax

Practice location:
  • Phone: 401-421-1710
  • Fax: 401-861-2164
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD6286
License Number StateRI

VIII. Authorized Official

Name: CLAUDIA A IACOBBO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 401-421-1710