Provider Demographics
NPI:1972557346
Name:SMALL, PETER MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:SMALL
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:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-1340
Mailing Address - Country:US
Mailing Address - Phone:401-788-8212
Mailing Address - Fax:401-788-8125
Practice Address - Street 1:200 HIGH SERVICE AVENUE
Practice Address - Street 2:ST. JOSEPH HEALTH SERVICES OF RHODE ISLAND
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-490-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8002001Medicaid
C90441Medicare UPIN
RI8002001Medicaid
RI088002001Medicare PIN