Provider Demographics
NPI:1982657995
Name:GRAVALLESE, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GRAVALLESE
Suffix:
Gender:M
Credentials:
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 603314
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-0714
Mailing Address - Country:US
Mailing Address - Phone:401-274-8110
Mailing Address - Fax:401-861-5220
Practice Address - Street 1:101 DUDLEY ST
Practice Address - Street 2:WOMEN & INFANTS HOSPITAL
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2401
Practice Address - Country:US
Practice Address - Phone:401-274-1122
Practice Address - Fax:401-453-7533
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09572207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006149Medicaid
RI007006149Medicare PIN
G60795Medicare UPIN