Provider Demographics
NPI:1245220219
Name:SOARES, GREGORY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:SOARES
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 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD092612085R0204X, 2085R0202X
MA2137212085R0202X, 2085R0204X
RI92612085R0202X
RI092612085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000001988OtherNHPRI
243602OtherRIH PILGRIM
300128804OtherRAILROAD MEDICARE
2010674OtherMASSMEDICAID
007009508OtherHOSPITAL PIN
2282555OtherCIGNA
409500OtherBLUE CHIP
409517OtherTUFTS
16 50203OtherUNITED HEALTH PLANS
9261OtherBLUE SHIELD
7009506OtherRI MEDICAL ASSISTANCE
H54051Medicare UPIN
000000001988OtherNHPRI