Provider Demographics
NPI:1316017874
Name:PROVIDENCE CARDIOLOGY TESTING
Entity Type:Organization
Organization Name:PROVIDENCE CARDIOLOGY TESTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:HUG
Authorized Official - Last Name:KLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-521-0700
Mailing Address - Street 1:1 RANDALL SQ
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-521-0700
Mailing Address - Fax:401-521-0906
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:SUITE 305
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-521-0700
Practice Address - Fax:401-521-0906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI4568207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI849OtherBLUE CROSS
RI001218OtherBLUE CHIP
RI90002630Medicaid
RI001218OtherBLUE CHIP
RI90002630Medicaid