Basic Information
| Provider Information | |||||||||
| NPI: | 1043269582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLOW | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 ATWOOD AVE | ||||||||
| Address2: | DBA/ROBERT BUONANNO | ||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013516200 | ||||||||
| FaxNumber: | 4013516201 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 ATWOOD AVE | ||||||||
| Address2: | DBA/ROBERT BUONANNO | ||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013516200 | ||||||||
| FaxNumber: | 4013516201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00687 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7354 | 01 | RI | BCBS | OTHER | 204194/409026 | 01 | RI | BLUECHIP | OTHER | 1215115 | 01 | COVENTRY HEALTH | OTHER | CD1829 | 01 | RAILROAD MEDICARE | OTHER | 050397249 | 01 | RI | UNITEDHEALTHCARE | OTHER | 050397249 | 01 | PEQUOT PLUS HEALTH PLANS | OTHER | 0771230001 | 01 | SC | DME REGION C | OTHER | 1043269582 | 01 | TUFTS HEALTH PLANS | OTHER | 12296688 | 01 | MULTIPLAN | OTHER | 050397249 | 01 | FIRST HLTH/COVENTRY/HCVM | OTHER | 050397249 | 01 | WORKERS COMPENSATION | OTHER | 0771230001 | 01 | MA | DMEMAC REGION A | OTHER | 27673 | 01 | RI | NEIGHBORHOOD HEALTH PLANS | OTHER | AA64883 | 01 | MA | HARVARD HEALTH PLANS | OTHER |