Provider Demographics
NPI:1366402018
Name:DRS. CONCANNON AND VITALE, LLC
Entity type:Organization
Organization Name:DRS. CONCANNON AND VITALE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONCANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:401-943-7337
Mailing Address - Street 1:1145 RESERVOIR AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-943-7337
Mailing Address - Fax:401-942-1509
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-943-7337
Practice Address - Fax:401-942-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO-357208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI601200661Medicaid