Basic Information
| Provider Information | |||||||||
| NPI: | 1447221866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETIENNE | ||||||||
| FirstName: | ALEX | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562363 | ||||||||
| FaxNumber: | 4014566744 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562363 | ||||||||
| FaxNumber: | 4014566744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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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 | 207R00000X | MD11719 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0401X | MD11719 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 208M00000X | MD11719 | RI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7058051 | 05 | RI | MEDICAID | 412896 | 01 | RI | BLUE CHIP OF RI | OTHER | 29918 | 01 | RI | BLUE CROSS OF RI | OTHER |