1265567077 NPI number — ELMWOOD ORTHOPEDIC REHAB CENTER, INC.

Table of content: (NPI 1265567077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265567077 NPI number — ELMWOOD ORTHOPEDIC REHAB CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMWOOD ORTHOPEDIC REHAB CENTER, 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:
Provider Other Organization Name Type Code:
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:
1265567077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
193 ELMWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02907-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-459-4000
Provider Business Mailing Address Fax Number:
401-459-4005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 DUDLEY ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02905-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-941-1347
Provider Business Practice Location Address Fax Number:
617-445-7874
Provider Enumeration Date:
02/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YATSKAR
Authorized Official First Name:
IGOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
617-442-3462

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT01849 , 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: E061618 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".