Basic Information
| Provider Information | |||||||||
| NPI: | 1225184617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HEALTH SERVICES OF RI, | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. JOSEPH HOSP. FOR SPECIALTY CARE-PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014563000 | ||||||||
| FaxNumber: | 4014563762 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 PEACE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029071510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014564300 | ||||||||
| FaxNumber: | 4014564050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/19/2007 | ||||||||
| NPIReactivationDate: | 02/14/2014 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEIMIG | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4014563000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOSEPHS HEALTH SERVICES OF RI | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HOS00110 | RI | Y | Hospitals | General Acute Care Hospital |
No ID Information.