Provider Demographics
NPI:1508883596
Name:JURCZAK, ANNMARIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:JURCZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:1377 S COUNTY TRL UNIT 2A
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818
Practice Address - Country:US
Practice Address - Phone:401-606-3000
Practice Address - Fax:401-331-8110
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11667207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7057363Medicaid
RI007060687OtherMEDICARE PTAN
RI007057363Medicare PIN