Basic Information
| Provider Information | |||||||||
| NPI: | 1922036946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC PROFESSIONAL SERVICES OF RHODE ISLAND INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635998 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635998 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 KENYON AVENUE | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017828000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | ISTVAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5188421900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208M00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | DC9415 | 01 | RI | MEDICARE TRAVELERS RR - G | OTHER | 02821543 | 05 | NY | MEDICAID | 7003615 | 05 | RI | MEDICAID | 1018847630001 | 05 | PA | MEDICAID |