Provider Demographics
NPI:1043401979
Name:OCEAN MEDICAL PRACTICE, INC.
Entity Type:Organization
Organization Name:OCEAN MEDICAL PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIBRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-765-1200
Mailing Address - Street 1:20 CUMBERLAND HILL RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-4854
Mailing Address - Country:US
Mailing Address - Phone:401-765-1200
Mailing Address - Fax:401-765-1212
Practice Address - Street 1:20 CUMBERLAND HILL RD
Practice Address - Street 2:SUITE 208
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4854
Practice Address - Country:US
Practice Address - Phone:401-765-1200
Practice Address - Fax:401-765-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI9516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIOM69208Medicaid
RIOM69208Medicaid