=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356738819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT M SERRA, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2015
-----------------------------------------------------
Last Update Date | 04/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 CANYON DR
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-523-1827
-----------------------------------------------------
Fax | 401-637-7844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 CANYON DR
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-523-1827
-----------------------------------------------------
Fax | 401-637-7844
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT M SERRA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 401-523-1827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------