Basic Information
| Provider Information | |||||||||
| NPI: | 1508883596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JURCZAK | ||||||||
| FirstName: | ANNMARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1377 S COUNTY TRL UNIT 2A | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016063000 | ||||||||
| FaxNumber: | 4013318110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD11667 | RI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7057363 | 05 | RI | MEDICAID | 007060687 | 01 | RI | MEDICARE PTAN | OTHER |