Basic Information
| Provider Information | |||||||||
| NPI: | 1306064563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | ETHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4019219212 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4019219212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD12864 | RI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | LP00309 | RI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 12864 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.