1295811057 NPI number — HAROLD GOLDIS LICSW

Table of content: HAROLD GOLDIS LICSW (NPI 1295811057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295811057 NPI number — HAROLD GOLDIS LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDIS
Provider First Name:
HAROLD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

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:
1295811057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 899
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:
02879-2222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-364-7705
Provider Business Mailing Address Fax Number:
401-364-7705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 BACON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWTUCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02860-5542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-722-3560
Provider Business Practice Location Address Fax Number:
401-722-3593
Provider Enumeration Date:
10/27/2006

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 050306183 . This is a "MULTIPLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050306183 . This is a "MAGELLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 233232 . This is a "TRICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 6234382 . This is a "UBH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: A007959 . This is a "VALUE OPTIONS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 1020890 . This is a "BEACON NHP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 306186 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 406478 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: HG13028 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: RI0007930 . This is a "CHAMPUS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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