Provider Demographics
NPI:1437275104
Name:GERSHON, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GERSHON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-8709
Mailing Address - Country:US
Mailing Address - Phone:401-885-4088
Mailing Address - Fax:401-823-9180
Practice Address - Street 1:889 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4342
Practice Address - Country:US
Practice Address - Phone:401-821-4100
Practice Address - Fax:401-823-9180
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00171103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI6108438OtherUNITED HAELTH PROVIDER #
RI0000030545OtherRI BLUE CROSS PROVIDER #
RIMG51041Medicaid
RI000873OtherRI BLUE CHIP PROVIDER #
RIMG51041Medicaid