1669622478 NPI number — JACK P MOURAD,MD,INC

Table of content: (NPI 1669622478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669622478 NPI number — JACK P MOURAD,MD,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK P MOURAD,MD,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:
1669622478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 AUBURN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02910-2852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-461-8450
Provider Business Mailing Address Fax Number:
401-461-8640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 AUBURN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRANSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02910-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-461-8450
Provider Business Practice Location Address Fax Number:
401-461-8640
Provider Enumeration Date:
09/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOURAD
Authorized Official First Name:
JACK
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-461-8450

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  8219 , 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: 9002703 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110179243 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 22724 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2703-4 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 04-01308 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 64476 . This is a "HARVARD PILGRIM HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com