Healthcare Provider Details

I. General information

NPI: 1306064563
Provider Name (Legal Business Name): ETHAN PRINCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

IV. Provider business mailing address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-2520
  • Fax: 401-921-9212
Mailing address:
  • Phone: 401-432-2520
  • Fax: 401-921-9212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD12864
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberLP00309
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number12864
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: