1619980018 NPI number — FELLOWSHIP HEALTH RESOURCES, INC

Table of content: (NPI 1619980018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619980018 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:
1619980018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 ALBION RD STE 420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02865-3744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-333-3980
Provider Business Mailing Address Fax Number:
401-334-8862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23769 SHORTLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19947-4754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-856-7642
Provider Business Practice Location Address Fax Number:
302-856-7658
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUSCH
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR CONTRACTS & CREDENTIALING
Authorized Official Telephone Number:
445-201-3028

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  1062 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000333061 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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