Provider Demographics
NPI:1285644096
Name:ECONOMOS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ECONOMOS
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 1:215 TOLL GATE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4458
Mailing Address - Country:US
Mailing Address - Phone:401-732-5600
Mailing Address - Fax:401-734-9400
Practice Address - Street 1:215 TOLLGATE ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4326
Practice Address - Country:US
Practice Address - Phone:401-732-5600
Practice Address - Fax:401-734-9400
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD9195207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9025255Medicaid
RI1690252551Medicare PIN