Provider Demographics
NPI:1730634254
Name:DANIEL T SHREVE MD INC
Entity type:Organization
Organization Name:DANIEL T SHREVE MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHREVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-434-9100
Mailing Address - Street 1:47 HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-3309
Mailing Address - Country:US
Mailing Address - Phone:401-434-9100
Mailing Address - Fax:401-434-4732
Practice Address - Street 1:47 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-3309
Practice Address - Country:US
Practice Address - Phone:401-434-9100
Practice Address - Fax:401-434-4732
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DANIEL T SHREVE MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD03558302F00000X, 305S00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001447Medicaid
RI1134239767OtherDANIEL T SHREVE MD INC
RI1134239767OtherDANIEL T SHREVE MD INC