Provider Demographics
NPI:1447502729
Name:GEORGE J JACEWICZ, M. D., INC
Entity type:Organization
Organization Name:GEORGE J JACEWICZ, M. D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-738-6111
Mailing Address - Street 1:95 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4443
Mailing Address - Country:US
Mailing Address - Phone:401-738-6111
Mailing Address - Fax:401-732-0155
Practice Address - Street 1:95 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4443
Practice Address - Country:US
Practice Address - Phone:401-738-6111
Practice Address - Fax:401-732-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI4047207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGJ00045Medicaid
RIC90236Medicare UPIN
RI049000777Medicare PIN