Provider Demographics
NPI:1306816251
Name:SOUTH COUNTY PRIMARY CARE, INC.
Entity Type:Organization
Organization Name:SOUTH COUNTY PRIMARY CARE, INC.
Other - Org Name:SOUTH COUNTY WALK IN AND PRIMARY CARE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-789-1086
Mailing Address - Street 1:360 KINGSTOWN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3239
Mailing Address - Country:US
Mailing Address - Phone:401-789-1086
Mailing Address - Fax:401-789-5344
Practice Address - Street 1:360 KINGSTOWN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3239
Practice Address - Country:US
Practice Address - Phone:401-789-1086
Practice Address - Fax:401-789-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI407659OtherBLUECHIP
RI9000328Medicaid
RI1962OtherNHPRI
22374-2OtherBCBS
44-00013OtherUNITED HEALTH PLAN
RI2464OtherNHP
111745OtherHEALTH PARTNERS
=========OtherTID
RI9000328Medicaid