Provider Demographics
NPI:1275064198
Name:MCEACHERN, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:MCEACHERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-459-7950
Mailing Address - Fax:
Practice Address - Street 1:100 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3233
Practice Address - Country:US
Practice Address - Phone:401-453-7950
Practice Address - Fax:401-453-7748
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-071020207R00000X
RIMD17135207RB0002X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program