Provider Demographics
NPI:1811905169
Name:EAST PROVIDENCE FOOTCARE,INC.
Entity type:Organization
Organization Name:EAST PROVIDENCE FOOTCARE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DIMATTEO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:401-438-8090
Mailing Address - Street 1:PO BOX 3160
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-0803
Mailing Address - Country:US
Mailing Address - Phone:978-474-8885
Mailing Address - Fax:978-474-8845
Practice Address - Street 1:224 TAUNTON AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-3731
Practice Address - Country:US
Practice Address - Phone:401-438-8090
Practice Address - Fax:401-435-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPMO198213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9018099Medicaid
RI9018099Medicaid
RI4718450001Medicare NSC