Basic Information
| Provider Information | |||||||||
| NPI: | 1548803729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LANDMARK MEDICAL OF RHODE ISLAND PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7755 CENTER AVE STE 630 | ||||||||
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| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926479152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6574005180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 CHESTNUT ST | ||||||||
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| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174205316 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2019 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6574005180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.