Provider Demographics
NPI:1184010118
Name:MPCH
Entity Type:Organization
Organization Name:MPCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATEWIDE MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GROBLEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:781-706-1052
Mailing Address - Street 1:149 POMONA AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-5123
Mailing Address - Country:US
Mailing Address - Phone:978-425-4341
Mailing Address - Fax:
Practice Address - Street 1:149 POMONA AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-5123
Practice Address - Country:US
Practice Address - Phone:978-425-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MHM HEALTH PROFESSIONAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269378302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization