Basic Information
| Provider Information | |||||||||
| NPI: | 1811179906 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NICHOLAS IANNUCCILLI MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 STILES RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030792846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038939784 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 SMITH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029112947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013531600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | IANNUCCILLI | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4013531600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0000000763 | 01 | RI | BCBS | OTHER | 9000763 | 05 | RI | MEDICAID |