Provider Demographics
NPI:1275668006
Name:EAST BAY NEUROLOGY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EAST BAY NEUROLOGY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOTASEM
Authorized Official - Middle Name:A
Authorized Official - Last Name:AL YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-724-4100
Mailing Address - Street 1:333 SCHOOL ST STE 216
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5336
Mailing Address - Country:US
Mailing Address - Phone:401-722-7300
Mailing Address - Fax:401-722-7390
Practice Address - Street 1:333 SCHOOL ST STE 216
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-722-7300
Practice Address - Fax:401-722-7390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00999103G00000X
RIMD 095012084N0400X
MA2123682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006029Medicaid
G56468Medicare UPIN
RI7006029Medicaid
RI5915640001Medicare NSC