Basic Information
| Provider Information | |||||||||
| NPI: | 1902027808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MIRIAM HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445640 | ||||||||
| FaxNumber: | 4014445462 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014445640 | ||||||||
| FaxNumber: | 4014445462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | WAKEFIELD | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE EVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4014445640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE MIRIAM HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | HOS0012206 | RI | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 27977 | 01 | RI | TB GRP NUMBER NHPRI | OTHER |