Individual
JACK R BEVIVINO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
120 DUDLEY STREET, SUITE #201, PROVIDENCE, RI 02905-2431
(401) 521-9290
(401) 521-9297
Mailing address
120 DUDLEY STREET, SUITE #201, PROVIDENCE, RI 02905-2431
(401) 521-9290
(401) 521-9297
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
RIMD05259
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1300124
UNITED HEALTH CARE
RI
01
—
21126
BCBS
RI
05
—
9002112
—
RI
Enumeration date
04/03/2007
Last updated
07/08/2007
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