Healthcare Provider Details

I. General information

NPI: 1154206308
Provider Name (Legal Business Name): BAILA MIR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BULLOCKS POINT AVE
RIVERSIDE RI
02915-5351
US

IV. Provider business mailing address

100 BULLOCKS POINT AVE
RIVERSIDE RI
02915-5351
US

V. Phone/Fax

Practice location:
  • Phone: 401-437-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01823
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: