Provider Demographics
NPI:1609877489
Name:BRASSARD, PETER GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GEORGE
Last Name:BRASSARD
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 1:1053 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-4729
Mailing Address - Country:US
Mailing Address - Phone:401-438-5551
Mailing Address - Fax:401-438-7272
Practice Address - Street 1:1053 S BROADWAY
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-4729
Practice Address - Country:US
Practice Address - Phone:401-438-5551
Practice Address - Fax:401-438-7272
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICMD06972207Q00000X
TXG7396207Q00000X
MA150111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2047248OtherHEALTH CARE VALUE MGMT
RI26953OtherBLUE CROSS BLUE SHIELD
RI9374902OtherPHCS
RI0103881OtherUNITED HEALTH CARE
RI200861OtherBLUE CHIP (BCBSRI)
RI2047248OtherCCN
RI12287833OtherMULTIPLAN
RI2047248OtherFIRST HEALTH
RI200861OtherBLUE CHIP (BCBSRI)
RI2047248OtherCCN