Provider Demographics
NPI:1285857219
Name:E.P. MENNILLO, M.D., INC
Entity Type:Organization
Organization Name:E.P. MENNILLO, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:MENNILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-944-8422
Mailing Address - Street 1:994 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5122
Mailing Address - Country:US
Mailing Address - Phone:401-944-8422
Mailing Address - Fax:401-942-6995
Practice Address - Street 1:994 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-5122
Practice Address - Country:US
Practice Address - Phone:401-944-8422
Practice Address - Fax:401-942-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI092212080A0000X
RI030332080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIC90636Medicare UPIN
RIG59520Medicare UPIN