1164636890 NPI number — AQUIDNECK PODIATRY LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164636890 NPI number — AQUIDNECK PODIATRY LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AQUIDNECK PODIATRY LTD
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:
1164636890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 MEMORIAL BOULEVARD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02840-3679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-846-2800
Provider Business Mailing Address Fax Number:
401-849-4899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 MEMORIAL BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02840-3679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-846-2800
Provider Business Practice Location Address Fax Number:
401-849-4899
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORNELL
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT AQUIDNECK PODIATRY LTD
Authorized Official Telephone Number:
401-846-2800

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DPM 00195 , 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: 2700178 . This is a "UNITED HEALTH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 71215 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9007121 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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