Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207QA0000X | Family Medicine | Adolescent Medicine | MD05716 | RHODE ISLAND | No |
| 2 | 208000000X | Pediatrics | | MD05716 | RHODE ISLAND | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 10/01/2008 | OTHER | RHODE ISLAND | BCBS |
| 2 | 12/29/2008 | OTHER | MASSACHUSETTS | TUFTS HEALTH PLAN |
| 3 | 939025129 | OTHER | RHODE ISLAND | RI MEDICARE GROUP NUMBER |
| 4 | 3206211 | MEDICAID | MASSACHUSETTS | |
| 5 | 04/15/2009 | OTHER | RHODE ISLAND | UNITED HEALTH CARE |
| 6 | 11/12/2009 | OTHER | RHODE ISLAND | NHPRI |
| 7 | 007008106 | OTHER | RHODE ISLAND | MEDICARE - TYPE UNSPECIFI |
| 8 | 1215047618 | OTHER | RHODE ISLAND | NPI |
| 9 | C90230 | MEDICARE UPIN | RHODE ISLAND | |
| 10 | 7002203 | MEDICAID | RHODE ISLAND | |
