Provider Demographics
NPI:1962409649
Name:ETTER, GREGG M (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:M
Last Name:ETTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2363
Mailing Address - Fax:401-456-6744
Practice Address - Street 1:2756 POST RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-3003
Practice Address - Country:US
Practice Address - Phone:401-691-6000
Practice Address - Fax:401-738-7718
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08688103TA0400X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004198Medicaid
RI7004198Medicaid
RI007056655Medicare ID - Type Unspecified