1164575338 NPI number — PROVIDENCE MEDICAL HEALTHCARE CENTER

Table of content: (NPI 1164575338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164575338 NPI number — PROVIDENCE MEDICAL HEALTHCARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE MEDICAL HEALTHCARE CENTER
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:
6
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:
1164575338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 DEAN ST
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:
02903-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-521-3270
Provider Business Mailing Address Fax Number:
401-521-6532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 DEAN ST
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:
02903-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-521-3270
Provider Business Practice Location Address Fax Number:
401-521-6532
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VITELLI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
SILVIO
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
401-521-3270

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PM24729 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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