Provider Demographics
NPI:1750442794
Name:MAIN, ROY M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:M
Last Name:MAIN
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 1:6 REED DR
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-3934
Mailing Address - Country:US
Mailing Address - Phone:401-580-1788
Mailing Address - Fax:
Practice Address - Street 1:6 REED DR
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-3934
Practice Address - Country:US
Practice Address - Phone:401-580-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001318650Medicaid
CT001318650Medicaid
CT110008581Medicare ID - Type Unspecified