Provider Demographics
NPI:1295952802
Name:PERIS MEDICAL CORPORATION
Entity type:Organization
Organization Name:PERIS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ-PERIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-226-6248
Mailing Address - Street 1:655 BROAD STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1510
Mailing Address - Country:US
Mailing Address - Phone:401-383-6748
Mailing Address - Fax:
Practice Address - Street 1:655 BROAD STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-383-6748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIER48067Medicaid
RI119082051Medicare PIN
RIER48067Medicaid