Provider Demographics
NPI:1891288627
Name:TAREILA, ANDREW MARC (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARC
Last Name:TAREILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 METRO CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1768
Mailing Address - Country:US
Mailing Address - Phone:401-432-2500
Mailing Address - Fax:401-921-9212
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5127
Practice Address - Fax:401-444-3056
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD171852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILP04344OtherLICENSE NUMBER