Healthcare Provider Details

I. General information

NPI: 1063876423
Provider Name (Legal Business Name): ERIC MASTROGIACOMO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

3824 NORTHERN PIKE STE 700
MONROEVILLE PA
15146-2184
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-7010
  • Fax: 401-736-4546
Mailing address:
  • Phone: 412-457-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS020645
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO01273
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: