Basic Information
| Provider Information | |||||||||
| NPI: | 1215077748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOMASSIMO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 SOCKANOSSET CROSS RD | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029205536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019447574 | ||||||||
| FaxNumber: | 4019447602 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 SOCKANOSSET CROSS RD | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029205536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019447574 | ||||||||
| FaxNumber: | 4019447602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00783 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT00783 | 01 | RI | STATE LICENSE NUMBER | OTHER |