Basic Information
| Provider Information | |||||||||
| NPI: | 1457346413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWPORT HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445640 | ||||||||
| FaxNumber: | 4014445462 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 FRIENDSHIP ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446966 | ||||||||
| FaxNumber: | 4014445462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAKEFIELD | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4014447914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFESPAN CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 127 | RI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1858 | 01 | RI | MVP PROVIDER ID | OTHER | 0000000005 | 01 | RI | BCBSRI PROVIDER ID | OTHER | 1929 | 01 | RI | NHPRI PROVIDER ID | OTHER | A0290102 | 01 | RI | JOHN DEERE HLTH PROV ID | OTHER | 000000023994 | 01 | RI | BOSTON MED CTR PROV ID | OTHER | H00103 | 01 | RI | BLUE CHIP PROVIDER ID | OTHER | 0060318 | 01 | RI | AETNA PROVIDER ID | OTHER | 4100006 | 05 | RI | MEDICAID | 5000226 | 01 | RI | UHCNE HOSPITAL PROV ID | OTHER | 905155 | 01 | RI | TUFTS INPT PROVIDER ID | OTHER | 900253 | 01 | RI | TUFTS OP PROVIDER ID | OTHER | RI0014 | 01 | RI | HEALTHNET NE PROV ID | OTHER | 999076 | 01 | RI | CONNECTICARE PROV ID | OTHER | OP00006 | 05 | RI | MEDICAID |