Provider Demographics
NPI:1114186715
Name:ST JOSEPH HEALTH SERVICES OF RHODE ISLAND
Entity Type:Organization
Organization Name:ST JOSEPH HEALTH SERVICES OF RHODE ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-456-3309
Mailing Address - Street 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:4TH FL MARION HALL
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3309
Mailing Address - Fax:401-456-3762
Practice Address - Street 1:21 PEACE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-3309
Practice Address - Fax:401-456-3762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIHOS00110133N00000X, 171R00000X, 207Q00000X, 207V00000X
RIHOS001100207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Single Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2127OtherPROGROUP (NHP)