1346394616 NPI number — JENNIFER SOUTHER MD INC

Table of content: (NPI 1346394616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346394616 NPI number — JENNIFER SOUTHER MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNIFER SOUTHER MD 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:
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:
1346394616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 MARTIN ST
Provider Second Line Business Mailing Address:
UNIT 30A
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02864-5321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-334-4500
Provider Business Mailing Address Fax Number:
401-312-0096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MARTIN ST
Provider Second Line Business Practice Location Address:
UNIT 30A
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02864-5321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-334-4500
Provider Business Practice Location Address Fax Number:
401-312-0096
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSO
Authorized Official First Name:
CARYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
401-334-4500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD10848 , 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: 01-02493 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 32087-4 . This is a "BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 409677 . This is a "BLUE CHIP OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 12001018 . This is a "MULTIPLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: MD10848 . This is a "LIC" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: AA242 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com