275 Waivered Practitioner Annual Reporting Form See First Name 2, Stat. Medical Number 5. ADDRESS OF PRIMARY LOCATION 270 Road Addr. SS 2 North Stat. Rhode Island Name Stat. Rhode Island Last Name G. TELEPHONE NUMBER 401-295-0012 Extension (if 7. FAX NUMBER 8. EMAIL ADDRESS Confirm Em all Address this Date TBD e Statement suffix 4_ NPI and Number ….