Basic Information
| Provider Information | |||||||||
| NPI: | 1205112935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHEN J D'AMATO MD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 211 QUAKER LN | ||||||||
| Address2: | |||||||||
| City: | WEST WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028932151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012707077 | ||||||||
| FaxNumber: | 4012702781 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 QUAKER LN | ||||||||
| Address2: | |||||||||
| City: | WEST WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028932151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012707077 | ||||||||
| FaxNumber: | 4012702781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2011 | ||||||||
| LastUpdateDate: | 05/13/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | D'AMATO | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4012707077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | MD05562 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207P00000X | MD05562 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | MD05562 | RI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0410540001 | 01 | RI | DME | OTHER | 1203-0 | 01 | BCROSS | OTHER | 9001203 | 05 | RI | MEDICAID | 00002400188 03 | 01 | RI | UHC | OTHER |