Basic Information
Provider Information | |||||||||
NPI: | 1992840862 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. JOSEPH HEALTH SERVICES OF RI | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATHOLOGY GROUP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 HIGH SERVICE AVE | ||||||||
Address2: | 4TH FL. MARION HALL | ||||||||
City: | NORTH PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029045113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014563309 | ||||||||
FaxNumber: | 4014563762 | ||||||||
Practice Location | |||||||||
Address1: | 200 HIGH SERVICE AVE | ||||||||
Address2: |   | ||||||||
City: | NORTH PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029045113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014563309 | ||||||||
FaxNumber: | 4014563762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2007 | ||||||||
LastUpdateDate: | 07/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 09/19/2007 | ||||||||
NPIReactivationDate: | 12/22/2009 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOGARTY | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4014563309 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST JOSEPH HEALTH SERVICES OF RI | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CEO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | HOS00110 | RI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 282N00000X | HOS00110 | RI | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | SJ09278 | 05 | RI |   | MEDICAID |