1669690418 NPI number — CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS INC

Table of content: (NPI 1669690418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669690418 NPI number — CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRANSTON PEDIATRICS LLC DBA PARK PEDIATRICS 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:
PARK PEDIATRICS, INC
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:
1669690418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 PARK AVE
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:
02910-2036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-274-6575
Provider Business Mailing Address Fax Number:
401-273-2597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 PARK AVE
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:
02910-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-274-6575
Provider Business Practice Location Address Fax Number:
401-273-2597
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUILES
Authorized Official First Name:
RICK
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-274-6575

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD11641 , 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: 412877 . This is a "HEALTHMATE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: MD 11641 . This is a "LICENSE NUMBER" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 30943 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 31923-4 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 25-79403 . This is a "UNITED HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 412877 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9004316 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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