Provider Demographics
NPI:1073864591
Name:PEDIATRIC ENDOCRINOLOGY OF RHODE ISLAND
Entity Type:Organization
Organization Name:PEDIATRIC ENDOCRINOLOGY OF RHODE ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/ MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCEACHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-419-8091
Mailing Address - Street 1:50 AMARAL ST
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2205
Mailing Address - Country:US
Mailing Address - Phone:401-434-2058
Mailing Address - Fax:401-633-6854
Practice Address - Street 1:105 SOCKANOSSET CROSS ROAD
Practice Address - Street 2:SUITE 318
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920
Practice Address - Country:US
Practice Address - Phone:401-434-2058
Practice Address - Fax:401-633-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI113122080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3300486OtherUNITED HEALTHCARE
RIPE91323Medicaid
3300486OtherUNITED HEALTHCARE
007050156Medicare UPIN