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General NPI Number Information
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NPI Number | 1275668006
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Entity Type | Organization
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Legal Business Name | EAST BAY NEUROLOGY PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 333 SCHOOL ST STE 216
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City | PAWTUCKET
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State | RI
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Zip | 02860
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Country | US
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Telephone | 401-722-7300
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Fax | 401-722-7390
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Provider Business Mailing Address
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Address Line | 333 SCHOOL ST STE 216
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City | PAWTUCKET
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State | RI
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Zip | 02860-5336
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Country | US
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Telephone | 401-722-7300
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Fax | 401-722-7390
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Authorized Official
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Title or Position | PRESIDENT
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Name | MOTASEM A AL YACOUB
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Credential | MD
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Telephone | 401-724-4100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PS00999
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 212368
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | MD 09501
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License Number State | RI
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