Healthcare Provider Details

I. General information

NPI: 1639162951
Provider Name (Legal Business Name): GEORGE J. JACEWICZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
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:
Title or Position:
Credential:
Phone: