Provider Demographics
NPI:1184687956
Name:MEDEIROS, MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ADAMS DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-5428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 ADAMS DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-5428
Practice Address - Country:US
Practice Address - Phone:401-849-0098
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAT000202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer