Basic Information
| Provider Information | |||||||||
| NPI: | 1154316370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERROL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10 DAVOL SQ | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014214000 | ||||||||
| FaxNumber: | 4012721456 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017830084 | ||||||||
| FaxNumber: | 4017820005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00182 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9003699 | 05 | RI | MEDICAID | 979003699 | 01 | MEDICARE | OTHER | 709004434 | 01 | RI | GROUP MEDICARE | OTHER | 9003699 | 05 | SC | MEDICAID |