Basic Information
| Provider Information | |||||||||
| NPI: | 1841335775 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HEALTH SERVICES OF RI | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIOVASCULAR GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | NORTH 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: | 4014563000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/19/2007 | ||||||||
| NPIReactivationDate: | 12/03/2009 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELCHER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4014562525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | HOS00110 | RI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | SJ48636 | 05 | RI | MEDICAID |