1922239995 NPI number — HEIDI C. O'GRADY PT

Table of content: HEIDI C. O'GRADY PT (NPI 1922239995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922239995 NPI number — HEIDI C. O'GRADY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'GRADY
Provider First Name:
HEIDI
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORD
Provider Other First Name:
HEIDI
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922239995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRANSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02920-0944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-785-1016
Provider Business Mailing Address Fax Number:
401-785-1018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1529 ATWOOD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
02919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-351-0515
Provider Business Practice Location Address Fax Number:
401-351-0530
Provider Enumeration Date:
08/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00275 , 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: PT00275 . This is a "STATE LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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