1245239680 NPI number — FELLOWSHIP HEALTH RESOURCES, INC

Table of content: (NPI 1245239680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245239680 NPI number — FELLOWSHIP HEALTH RESOURCES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELLOWSHIP HEALTH RESOURCES, 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:
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:
1245239680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 ALBION RD
Provider Second Line Business Mailing Address:
SUITE 420
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02865-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-642-4416
Provider Business Mailing Address Fax Number:
401-642-4453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 ALBION RD
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02865-3311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-642-4416
Provider Business Practice Location Address Fax Number:
401-642-4453
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BUSCH
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR. OF CONTRACTS AND CREDENTIALING
Authorized Official Telephone Number:
445-206-3028

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: MHL-092-684 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , with the licence number: MHL-092-683 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100814610-0018 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004945662 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000022578 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100814610-0020 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15626000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10000656461 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100814610-0023 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NE02149 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004944038 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100814610-0013 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245239680 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000656461 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100814610-0019 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NE02148 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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