Basic Information
| Provider Information | |||||||||
| NPI: | 1285779116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HEALTH SERVICES OF RHODE ISLAND | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERN NEW ENGLAND REHABILITION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562525 | ||||||||
| FaxNumber: | 4014566742 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | N PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014563000 | ||||||||
| FaxNumber: | 4014566742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELCHER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4014562000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOSEPH HEALTH SERVICES OF RI | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | HOS00110 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 282N00000X | HOS00110 | RI | N | Hospitals | General Acute Care Hospital | 273Y00000X | HOS00110 | RI | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 9006651 | 05 | RI | MEDICAID |