Provider Demographics
NPI:1265857007
Name:OCEAN STATE PRIMARY CARE CENTER OF WESTERLY, LLC
Entity Type:Organization
Organization Name:OCEAN STATE PRIMARY CARE CENTER OF WESTERLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:HAMILTON
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-596-6464
Mailing Address - Street 1:77 FRANKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891
Mailing Address - Country:US
Mailing Address - Phone:401-596-6464
Mailing Address - Fax:401-348-8660
Practice Address - Street 1:77 FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891
Practice Address - Country:US
Practice Address - Phone:401-596-6464
Practice Address - Fax:401-348-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty