Provider Demographics
NPI:1114940681
Name:PROVIDENCE VA MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE VA MEDICAL CENTER
Other - Org Name:SOUTHEASTERN PSYCHIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF STAFF
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-273-7100
Mailing Address - Street 1:830 CHALKSTONE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02098-4799
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:401-457-3354
Practice Address - Street 1:830 CHALKSTONE AVENUE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02098-4799
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:401-457-3354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI18598261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health