Basic Information
| Provider Information | |||||||||
| NPI: | 1851303614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | BARRINGTON URGENT CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1908 | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028621908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017292836 | ||||||||
| FaxNumber: | 4017262721 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028063430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012472870 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIETZ | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4017292000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | HOS00128 | RI | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 9025321 | 05 | RI | MEDICAID |