1114003209 NPI number — DR. JUDITH M GILMORE M.D.

Table of content: DR. JUDITH M GILMORE M.D. (NPI 1114003209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114003209 NPI number — DR. JUDITH M GILMORE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
JUDITH
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1114003209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 229
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02880-0229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-788-8940
Provider Business Mailing Address Fax Number:
401-515-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 SALT POND RD
Provider Second Line Business Practice Location Address:
SUITE G2
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-788-8940
Provider Business Practice Location Address Fax Number:
401-515-2670
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  06935 , 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: 200353 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9000265 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 265-7 . This is a "BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 33-00015 . This is a "UHP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 41D0084370 . This is a "CLIA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 06935 . This is a "RI MEDICAL LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0930958 . This is a "AETA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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