1043431018 NPI number — PAWTUXET VALLEY MEDICAL, INC

Table of content: (NPI 1043431018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043431018 NPI number — PAWTUXET VALLEY MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAWTUXET VALLEY MEDICAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAWTUXET VALLEY URGENT CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043431018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
982 TIOGUE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVENTRY
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02816-6167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-821-6800
Provider Business Mailing Address Fax Number:
401-821-8513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
982 TIOGUE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVENTRY
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02816-6167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-821-6800
Provider Business Practice Location Address Fax Number:
401-821-8513
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-821-6800

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  4612 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0190006 . This is a "MEDICAID DME" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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