Provider Demographics
NPI:1568545580
Name:MEDEIROS, GREGG ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALLEN
Last Name:MEDEIROS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5015
Mailing Address - Country:US
Mailing Address - Phone:401-440-4228
Mailing Address - Fax:
Practice Address - Street 1:1196 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-3716
Practice Address - Country:US
Practice Address - Phone:401-461-1600
Practice Address - Fax:401-461-3500
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00545111N00000X, 111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0024812OtherMEDICARE PTAN
RI0024812OtherMEDICARE PTAN
RI359005054Medicare ID - Type Unspecified