Basic Information
| Provider Information | |||||||||
| NPI: | 1114186715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOSEPH HEALTH SERVICES OF RHODE ISLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | 4TH FL MARION HALL | ||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014563309 | ||||||||
| FaxNumber: | 4014563762 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 PEACE ST | ||||||||
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| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029071510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014563309 | ||||||||
| FaxNumber: | 4014563762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | FOGERTY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT - CEO | ||||||||
| AuthorizedOfficialTelephone: | 4014563309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | HOS00110 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | 171R00000X | HOS00110 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Interpreter | 207RE0101X | HOS001100 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207V00000X | HOS00110 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | HOS00110 | RI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2127 | 01 | RI | PROGROUP (NHP) | OTHER |