Basic Information
Provider Information | |||||||||
NPI: | 1508854472 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVANGELISTA | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
Address2: |   | ||||||||
City: | WARWICK | ||||||||
State: | RI | ||||||||
PostalCode: | 028861785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014322520 | ||||||||
FaxNumber: | 4014538220 | ||||||||
Practice Location | |||||||||
Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
Address2: |   | ||||||||
City: | WARWICK | ||||||||
State: | RI | ||||||||
PostalCode: | 028861785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014322520 | ||||||||
FaxNumber: | 4014538220 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2005 | ||||||||
LastUpdateDate: | 04/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD11408 | RI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 217024 | MA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 003124047 | 01 |   | CT MED ASSISTANCE | OTHER | 2465834 | 01 |   | CIGNA | OTHER | 9356928 | 01 |   | PHHCS | OTHER | 2081920 | 01 |   | MASSMEDICAID | OTHER | 3707988 | 01 |   | AETNA | OTHER | AA16956 | 01 |   | RIHPILGRIM | OTHER | P00120864 | 01 |   | RAILROAD MEDICARE | OTHER | 411628 | 01 |   | BLUECHIP | OTHER | 9003434 | 01 |   | RIMEDICALASSISTANCE | OTHER |