Provider Demographics
NPI:1992813273
Name:IANNUCCILLI, NICHOLAS D (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D
Last Name:IANNUCCILLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1515 SMITH ST
Mailing Address - Street 2:STE 6
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-2947
Mailing Address - Country:US
Mailing Address - Phone:401-353-1600
Mailing Address - Fax:
Practice Address - Street 1:1515 SMITH ST
Practice Address - Street 2:STE 6
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-2947
Practice Address - Country:US
Practice Address - Phone:401-353-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD044132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
6145612OtherMASS WELFARE
11237OtherNEIGHBORHOOD HEALTH RI GR
3412OtherGROUP RI BLUE SHIELD
710442OtherTUFTS
RI004035OtherBLUECHIP
245926OtherPILGRIM
RI7000911Medicaid
245926OtherPILGRIM
11237OtherNEIGHBORHOOD HEALTH RI GR