Provider Demographics
NPI:1740609981
Name:HAROLD J WANEBO MD LLC
Entity type:Organization
Organization Name:HAROLD J WANEBO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WANEBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-529-2828
Mailing Address - Street 1:1165 N MAIN ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5740
Mailing Address - Country:US
Mailing Address - Phone:401-529-2828
Mailing Address - Fax:401-943-1958
Practice Address - Street 1:1165 N MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5740
Practice Address - Country:US
Practice Address - Phone:401-529-2828
Practice Address - Fax:401-943-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD072002086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006428Medicaid