Provider Demographics
NPI:1730155482
Name:MENNILLO, ROGER NILES (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:NILES
Last Name:MENNILLO
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 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:176 TOLL GATE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4482
Practice Address - Country:US
Practice Address - Phone:401-737-9270
Practice Address - Fax:401-739-6413
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD09221208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRM51805Medicaid
RI659520Medicare UPIN
RIRM51805Medicaid