Basic Information
| Provider Information | |||||||||
| NPI: | 1992881437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRUESDALE MEDICAL PARTNERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
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| Address1: | 1030 PRESIDENT AVE | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086763411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | EIL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5086763411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 14286 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363A00000X | 1715 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | TM57357 | 05 | RI | MEDICAID |