Healthcare Provider Details

I. General information

NPI: 1730155482
Provider Name (Legal Business Name): ROGER NILES MENNILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 TOLL GATE RD SUITE 101
WARWICK RI
02886-4482
US

IV. Provider business mailing address

10 DAVOL SQ SUITE 400
PROVIDENCE RI
02903-4754
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-9270
  • Fax: 401-739-6413
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD09221
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: