Healthcare Provider Details

I. General information

NPI: 1447502729
Provider Name (Legal Business Name): GEORGE J JACEWICZ, M. D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 TOLL GATE RD
WARWICK RI
02886-4443
US

IV. Provider business mailing address

95 TOLL GATE RD
WARWICK RI
02886-4443
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-6111
  • Fax: 401-732-0155
Mailing address:
  • Phone: 401-738-6111
  • Fax: 401-732-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4047
License Number StateRI

VIII. Authorized Official

Name: GEORGE J JACEWICZ
Title or Position: OWNER
Credential: M.D.
Phone: 401-738-6111