| NPI |
1699867671 |
|
| Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Last Name Legal Name |
LIATSOS |
The last name of the provider. If the provider is an individual, this is the legal name. |
| Provider First Name |
NICHOLAS |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
STAUROS |
The middle name of the provider, if the provider
is an individual. |
| Provider Name Prefix Text |
MR. |
The name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
| Provider Credential Text |
PT |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider First Line Business Practice Location Address |
99 FRENCHTOWN RD |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
EAST GREENWICH |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
RI |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Postal Code |
028181802 |
The fax number associated with the location
address of the provider being identified. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider Business Practice Location Address Telephone Number |
4018846456 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
4018843210 |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Provider Enumeration Date |
9/28/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
7/8/2007 |
The title or position of the authorized official. |
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
174400000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 1 |
PT02026 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
RI |
|
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
Y |
|