Provider Demographics
NPI:1336108984
Name:DEMELIS, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DEMELIS
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 1:10 FAIRWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864
Mailing Address - Country:US
Mailing Address - Phone:401-405-0627
Mailing Address - Fax:
Practice Address - Street 1:211 PARK STREET
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703
Practice Address - Country:US
Practice Address - Phone:508-236-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220442207P00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2093448Medicaid
MAI09498Medicare UPIN
MA2093448Medicaid