Provider Demographics
NPI:1164627352
Name:EMMA PENDLETON BRADLEY HOSPITAL
Entity Type:Organization
Organization Name:EMMA PENDLETON BRADLEY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-444-7914
Mailing Address - Street 1:117 ELLENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:1011 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-5061
Practice Address - Country:US
Practice Address - Phone:401-444-5640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIHOS00123283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBH46731Medicaid