Provider Demographics
NPI:1689661241
Name:CORCORAN, J RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:J RUSSELL
Middle Name:
Last Name:CORCORAN
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 1:100 KENYON AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4216
Mailing Address - Country:US
Mailing Address - Phone:401-788-3929
Mailing Address - Fax:
Practice Address - Street 1:70 KENYON AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4239
Practice Address - Country:US
Practice Address - Phone:401-783-0084
Practice Address - Fax:401-782-0005
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06582207RG0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002371Medicaid
007056627OtherMEDICARE
RI050483739OtherTIN#
007056627OtherMEDICARE
RI007059287Medicare PIN