Basic Information
| Provider Information | |||||||||
| NPI: | 1518049469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENEREUX | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16149 | ||||||||
| Address2: | |||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029160697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539625 | ||||||||
| FaxNumber: | 4014357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 164 SUMMIT AVE | ||||||||
| Address2: | C70 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017933922 | ||||||||
| FaxNumber: | 4017937866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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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 | 363A00000X | 199 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA00199 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.