=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316217920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DOCTORS GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 01/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1445 WAMPANOAG TRL SUITE 205
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-474-3847
-----------------------------------------------------
Fax | 401-633-6094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1445 WAMPANOAG TRL SUITE 205
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-474-3847
-----------------------------------------------------
Fax | 401-633-6094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARGARET ANN SUN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 401-474-3847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 8624
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------