Provider Demographics
NPI:1134102841
Name:KARDOUS PRIMARY CARE INC
Entity Type:Organization
Organization Name:KARDOUS PRIMARY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTIOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KARDOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-946-5001
Mailing Address - Street 1:1145 RESERVOIR AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-946-5001
Mailing Address - Fax:401-946-5101
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:STE 301
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920
Practice Address - Country:US
Practice Address - Phone:401-946-5001
Practice Address - Fax:401-946-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI408195OtherBLUE CHIP
DB0254OtherRAILROAD MEDICARE
RI272209OtherBLUE CROSS BLUE SHIELD
RI9003208Medicaid
RI408195OtherBLUE CHIP