Provider Demographics
NPI:1790859064
Name:MORRISSEY, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:MORRISSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6064
Mailing Address - Country:US
Mailing Address - Phone:401-944-8700
Mailing Address - Fax:401-944-8767
Practice Address - Street 1:1150 RESERVOIR AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6064
Practice Address - Country:US
Practice Address - Phone:401-944-8700
Practice Address - Fax:401-944-8767
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06506207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002080Medicaid
RI200054OtherBLUE CHIP
RI2080OtherBC
C89880Medicare UPIN
RI209002080Medicare PIN