1306816251 NPI number — SOUTH COUNTY PRIMARY CARE, INC.

Table of content: (NPI 1306816251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306816251 NPI number — SOUTH COUNTY PRIMARY CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY PRIMARY CARE, 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:
SOUTH COUNTY WALK IN AND PRIMARY CARE, INC.
Provider Other Organization Name Type Code:
3
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:
1306816251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 KINGSTOWN RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
NARRAGANSETT
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02882-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-789-1086
Provider Business Mailing Address Fax Number:
401-789-5344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 KINGSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
NARRAGANSETT
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02882-3239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-789-1086
Provider Business Practice Location Address Fax Number:
401-789-5344
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
401-789-1086

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD09154 , 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: 407659 . This is a "BLUECHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9000328 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1962 . This is a "NHPRI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 22374-2 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44-00013 . This is a "UNITED HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2464 . This is a "NHP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 111745 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com