Provider Demographics
NPI:1558336669
Name:REALI MARINI, DIANE M (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:REALI MARINI
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:PO BOX 65377
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0377
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08740207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004493Medicaid
P00171398OtherRAILROAD
RI401700OtherBLUE CHIP
RI27419-1OtherBLUECROSS BLUESHIELD
RI27419-1OtherBLUECROSS BLUESHIELD
P00171398OtherRAILROAD