Basic Information
| Provider Information | |||||||||
| NPI: | 1407928179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOVASCULAR & INTERVENTIONAL ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 TEN ROD RD | ||||||||
| Address2: | D201 | ||||||||
| City: | NORTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028524161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012958655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 455 TOLL GATE RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028862759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017377010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | PAOLELLA | ||||||||
| AuthorizedOfficialFirstName: | LANDY | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4012958655 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | RI6315 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9020277 | 05 | CA | MEDICAID |