Provider Demographics
NPI:1013986140
Name:JUSSEAUME, SCOTT (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:JUSSEAUME
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 1:450 BROOK ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 BROOK ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2231
Practice Address - Country:US
Practice Address - Phone:401-863-3953
Practice Address - Fax:401-863-7953
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216386207Q00000X
RIMD19533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2080222Medicaid
MA2080222Medicaid
MAI09478Medicare UPIN