Healthcare Provider Details

I. General information

NPI: 1619234341
Provider Name (Legal Business Name): AMY EGOLF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. AMELIA NEBENHAUS

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1000
  • Fax: 401-432-1500
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD15497
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: