Provider Demographics
NPI:1275810434
Name:THE MIRIAM HOSPITAL
Entity Type:Organization
Organization Name:THE MIRIAM HOSPITAL
Other - Org Name:IMMUNOLOGY CENTER AT THE MIRIAM HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:MR
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 STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:014-446-7794
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:180 CORLISS ST STE E1
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2602
Practice Address - Country:US
Practice Address - Phone:401-793-7401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-15
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 1041C0700X, 2084P0800X
RIHOS00122261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI001629602Medicare Oscar/Certification