1699752923 NPI number — PRIME HEALTHCARE SERVICES LANDMARK LLC

Table of content: (NPI 1699752923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699752923 NPI number — PRIME HEALTHCARE SERVICES LANDMARK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME HEALTHCARE SERVICES LANDMARK LLC
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:
1699752923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 CASS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-4712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-769-4100
Provider Business Mailing Address Fax Number:
401-765-6024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 CASS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOONSOCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02895-4705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-769-4100
Provider Business Practice Location Address Fax Number:
401-769-1744
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DOAN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING ASSOCIATE GENERAL COUNSEL
Authorized Official Telephone Number:
310-259-4706

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  00117 , 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: 7029241 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 903288 . This is a "TUFTS HEALTH PLAN OUTPT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4100011 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 222921474 . This is a "TRICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 7000251 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000001930 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 903289 . This is a "TUFTS HEALTH PLAN INPAT." identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 900934 . This is a "HARVARD PILGRIM HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: OP00011 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000000010 . This is a "BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 5000704 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: H00104 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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