Basic Information
| Provider Information | |||||||||
| NPI: | 1477609816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCELLO | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 RICHMOND SQ STE 200 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014334172 | ||||||||
| FaxNumber: | 4014330612 | ||||||||
| Practice Location | |||||||||
| Address1: | 5750 POST RD STE 1A | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028182139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018852821 | ||||||||
| FaxNumber: | 4018845428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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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 | 225100000X | PT02047 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11825236 | 01 | RI | CAQH | OTHER | 1518921816 | 01 | RI | BUSINESS NPI | OTHER |