Basic Information
| Provider Information | |||||||||
| NPI: | 1356441562 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWPORT HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEWPORT EMERGENCY PHYSICIANS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11 FRIENDSHIP ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018451593 | ||||||||
| FaxNumber: | 4018470650 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 FRIENDSHIP ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018451593 | ||||||||
| FaxNumber: | 4018470650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEBEL | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4018451593 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWPORT HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9006743 | 05 | RI | MEDICAID |