Provider Demographics
NPI:1598762551
Name:MEDEIROS, GRACE A (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:MEDEIROS
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 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:401-683-1048
Mailing Address - Fax:401-683-1239
Practice Address - Street 1:2444 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-4025
Practice Address - Country:US
Practice Address - Phone:401-683-1048
Practice Address - Fax:401-683-1239
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD 091602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1598762551Medicaid
RI1598762551Medicaid
RI25354-3OtherRI BC/BS
RI7006205Medicaid
007006205Medicare ID - Type Unspecified