MEDICARE: DR. GREGG ALLEN MEDEIROS D.C.

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	111N00000X	Chiropractor	DCP00545	RI
2	111NI0013X	Independent Medical Examiner Chiropractor	DCP00545	RI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0024812	OTHER	RI	MEDICARE PTAN

General Provider Information

NPI Number	:	1568545580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG ALLEN MEDEIROS D.C.

Provider Business Mailing Address
First Line	:	43 MOUNTAIN AVE
Second Line	:
City	:	RIVERSIDE
State	:	RI
Zip	:	02915-5015
Country	:	US
Telephone Number	:	401-440-4228
Fax Number	:

Provider Business Practice Location Address
First Line	:	1196 ELMWOOD AVE
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02907-3716
Country	:	US
Telephone Number	:	401-461-1600
Fax Number	:	401-461-3500

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	05/23/2012

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