Provider First Line Business Practice Location Address: 
593 EDDY STREET
    Provider Second Line Business Practice Location Address: 
RHODE ISLAND HOSPITAL
    Provider Business Practice Location Address City Name: 
PROVIDENCE
    Provider Business Practice Location Address State Name: 
RI
    Provider Business Practice Location Address Postal Code: 
02903
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
401-444-2857
    Provider Business Practice Location Address Fax Number: 
401-444-6681
    Provider Enumeration Date: 
06/15/2017