Provider Demographics
NPI:1689749822
Name:GENTILESCO, BETHANY (MD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GENTILESCO
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:PO BOX 3238
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-0001
Mailing Address - Country:US
Mailing Address - Phone:866-689-8862
Mailing Address - Fax:207-347-7401
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2104
Practice Address - Fax:401-793-4047
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI32947-5OtherBCBS RI
RIAA99999OtherHPHC
RI1689749Medicaid
RI413923OtherBLUECHIP
RI1689749Medicaid
RI413923OtherBLUECHIP