Basic Information
Provider Information | |||||||||
NPI: | 1831450865 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST JOSEPH HEALTH SERVICES OF RI | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOSPITALIST GROUP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 HIGH SERVICE AVE | ||||||||
Address2: | ADMINISTRATION OFFICE, ATTN: R. SOARES | ||||||||
City: | NORTH PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029045113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014562525 | ||||||||
FaxNumber: | 4014566742 | ||||||||
Practice Location | |||||||||
Address1: | 200 HIGH SERVICE AVE | ||||||||
Address2: |   | ||||||||
City: | NORTH PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029045113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014563000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2012 | ||||||||
LastUpdateDate: | 06/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONKLIN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | SNR. VICE PRESIDENT, CFO | ||||||||
AuthorizedOfficialTelephone: | 4014563000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | HOS00110 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207R00000X | HOS00110 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0300X | HOS00110 | RI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 208M00000X | HO00110 | RI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | HOS00110 | 01 | RI | HOSPITAL LICENSE NUMBER | OTHER |