Provider Demographics
NPI:1598745986
Name:NILES, MICHAEL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:NILES
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 609
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-0609
Mailing Address - Country:US
Mailing Address - Phone:860-415-9248
Mailing Address - Fax:860-415-9237
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2922
Practice Address - Country:US
Practice Address - Phone:860-415-9248
Practice Address - Fax:860-415-9237
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD108182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD10818OtherSTATE RI LICENSE
RI7009817Medicaid
RI7009817Medicaid
RI7009817Medicaid