Provider Demographics
NPI:1497994826
Name:NEWPORT NEUROLOGIC AND ELECTRODIAGNOSTIC CENTER PC
Entity Type:Organization
Organization Name:NEWPORT NEUROLOGIC AND ELECTRODIAGNOSTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEDEIROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-619-5740
Mailing Address - Street 1:23 POWEL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2671
Mailing Address - Country:US
Mailing Address - Phone:401-619-5740
Mailing Address - Fax:401-619-5742
Practice Address - Street 1:23 POWEL AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2671
Practice Address - Country:US
Practice Address - Phone:401-619-5740
Practice Address - Fax:401-619-5742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD091602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty