Basic Information
| Provider Information | |||||||||
| NPI: | 1205858560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHONEY | ||||||||
| FirstName: | EMMY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 229 | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028800229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017883337 | ||||||||
| FaxNumber: | 4017883939 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KENYON AVE | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017883337 | ||||||||
| FaxNumber: | 4017883939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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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 | 207R00000X | 12145 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 12145 | RI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7058828 | 05 | RI | MEDICAID | 709003710 | 01 | RI | GROUP MEDICARE | OTHER |