Provider Demographics
NPI:1033464276
Name:BLACKSTONE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:BLACKSTONE MEDICAL CENTER, INC.
Other - Org Name:BLACKSTONE MEDICAL CENTER PSYCH
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-419-4772
Mailing Address - Street 1:219 CASS AVENUE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4741
Mailing Address - Country:US
Mailing Address - Phone:401-769-4100
Mailing Address - Fax:
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:401-769-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEWARD MEDICAL HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-13
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00117103G00000X, 103TP0016X, 207R00000X, 2084N0400X, 2084P0800X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI410011Medicare Oscar/Certification