Basic Information
Provider Information | |||||||||
NPI: | 1932154010 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POLVERINO | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | MARTHA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN BSN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 OLD COUNTY RD | ||||||||
Address2: | EAST BAY CENTER | ||||||||
City: | BARRINGTON | ||||||||
State: | RI | ||||||||
PostalCode: | 028061602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4012461195 | ||||||||
FaxNumber: | 4012461311 | ||||||||
Practice Location | |||||||||
Address1: | 2 OLD COUNTY RD | ||||||||
Address2: | EAST BAY CENTER | ||||||||
City: | BARRINGTON | ||||||||
State: | RI | ||||||||
PostalCode: | 028061602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4012461195 | ||||||||
FaxNumber: | 4012461311 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 10/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN34368 | RI | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | MP52680 | 05 | RI |   | MEDICAID |