=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104816628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN R CALDARELLI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2005
-----------------------------------------------------
Last Update Date | 10/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 SOCKANOSSET CROSSROADS
-----------------------------------------------------
City | CRANSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02920-6068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-943-1454
-----------------------------------------------------
Fax | 401-943-1140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6725 POST RD
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-886-4872
-----------------------------------------------------
Fax | 401-886-6184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD06483
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------