Provider Demographics
NPI:1033113477
Name:GEFFROY, GUY AE (MD)
Entity Type:Individual
Prefix:DR
First Name:GUY
Middle Name:AE
Last Name:GEFFROY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-5327
Mailing Address - Country:US
Mailing Address - Phone:401-783-2055
Mailing Address - Fax:401-783-3349
Practice Address - Street 1:500 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-5327
Practice Address - Country:US
Practice Address - Phone:401-783-2055
Practice Address - Fax:401-783-3349
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2008-07-11
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
RIRI3248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRI3248OtherRI LICENSE NUMBER
RI2783-8OtherBLUECROSS NUMBER
RI7001058Medicaid
RI050507059OtherFEDERAL TAX I.D. NUMBER 050507059
RI139002783Medicare ID - Type Unspecified
RI7001058Medicaid