MEDICARE: PAUL DIONISOPOULOS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	MD10188	RI
2	207R00000X	Internal Medicine Physician	RI10188	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0410540001	OTHER	RI	DME

General Provider Information

NPI Number	:	1225081813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL DIONISOPOULOS M.D.

Provider Business Mailing Address
First Line	:	1637 MINERAL SPRING AVE
Second Line	:	SUITE 115
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-4042
Country	:	US
Telephone Number	:	401-353-1012
Fax Number	:	401-353-6362

Provider Business Practice Location Address
First Line	:	1637 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-4042
Country	:	US
Telephone Number	:	401-353-1012
Fax Number	:	401-353-6362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	09/08/2014

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