Provider Demographics
NPI:1568458727
Name:VITHIANANTHAN, SIVAMAINTHAN (MD)
Entity Type:Individual
Prefix:
First Name:SIVAMAINTHAN
Middle Name:
Last Name:VITHIANANTHAN
Suffix:
Gender:M
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 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:195 COLLYER ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1869
Practice Address - Country:US
Practice Address - Phone:401-793-5140
Practice Address - Fax:401-793-5171
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80634208600000X
RIMD12377208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02109373Medicaid
NY02109373Medicaid
NYH15696Medicare UPIN