Provider Demographics
NPI:1225041064
Name:SOUTH COUNTY FAMILY MEDICINE INC.
Entity Type:Organization
Organization Name:SOUTH COUNTY FAMILY MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-539-0283
Mailing Address - Street 1:1111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832-1610
Mailing Address - Country:US
Mailing Address - Phone:401-539-0283
Mailing Address - Fax:401-539-6741
Practice Address - Street 1:1111 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832-1610
Practice Address - Country:US
Practice Address - Phone:401-539-0283
Practice Address - Fax:401-539-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI8814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISC42150Medicaid
RISC42150Medicaid