Basic Information
| Provider Information | |||||||||
| NPI: | 1326122557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HEALTH SERVICES OF RHODE ISLAND | ||||||||
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| OtherOrganizationName: | PSYCHIATRIC HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | N. CAMPUS BUSINESS OFFICE, ATTN; R. SOARES | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562525 | ||||||||
| FaxNumber: | 4014566742 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014563649 | ||||||||
| FaxNumber: | 4017528116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONKLIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SNR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4014563000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 110 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 273R00000X | HOS00110 | RI | N | Hospital Units | Psychiatric Unit | 282N00000X | HOS00110 | RI | N | Hospitals | General Acute Care Hospital | 2084P0800X | 110 | RI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | SJ09468 | 05 | RI | MEDICAID |