Provider Demographics
NPI:1417132549
Name:PETTERUTI FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:PETTERUTI FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PETTERUTI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:401-921-5934
Mailing Address - Street 1:250 CENTERVILLE RD
Mailing Address - Street 2:BUILDING E
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4382
Mailing Address - Country:US
Mailing Address - Phone:401-921-5934
Mailing Address - Fax:401-921-5936
Practice Address - Street 1:250 CENTERVILLE RD
Practice Address - Street 2:BUILDING E
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4382
Practice Address - Country:US
Practice Address - Phone:401-921-5934
Practice Address - Fax:401-921-5936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RID413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI089082071Medicare PIN