Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DCP00545 | RI |
Y | 111NI0013X | Independent Medical Examiner | DCP00545 | RI |
NPI | 1568545580 |
---|---|
Provider Name | Dr. Gregg Allen Medeiros |
First Address | Riverside, RI 02915-5015 |
Second Address | Providence, RI 02907-3716 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 23/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0024812 | MEDICARE PTAN (01) | RI |
V10328 | (02) | RI |