Provider Demographics
NPI:1578553830
Name:TETTEY, PEPPINO E (MD)
Entity Type:Individual
Prefix:
First Name:PEPPINO
Middle Name:E
Last Name:TETTEY
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 1:275 BROADWAY
Mailing Address - Street 2:UNIT 2
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2612
Mailing Address - Country:US
Mailing Address - Phone:401-845-1472
Mailing Address - Fax:401-846-4874
Practice Address - Street 1:11 FRIENDSHIP ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2271
Practice Address - Country:US
Practice Address - Phone:401-846-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10728207R00000X, 208M00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9025735Medicaid
RI29884-3OtherBC/BS
RI410635OtherBLUECHIP
RI9025735Medicaid
RI29884-3OtherBC/BS
007057880Medicare ID - Type Unspecified