Basic Information
| Provider Information | |||||||||
| NPI: | 1194739607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556200 | ||||||||
| FaxNumber: | 4014556309 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556200 | ||||||||
| FaxNumber: | 4014556309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD09220 | RI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | MD09220 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 9025185 | 05 | RI | MEDICAID | 1093831646 | 01 | BUTLER HOSPITAL PROFESSIONAL BILLING OFFICE NPI | OTHER | 1104801349 | 01 | BUTLER HOSPITAL NPI | OTHER | 15-37842 | 01 | RI | UNITED BEHAVIORAL HEALTH | OTHER | 25185-7 | 01 | RI | BLUE CROSS | OTHER | 400061 | 01 | RI | BLUE CHIP | OTHER |