Provider Demographics
NPI:1326122557
Name:ST. JOSEPH HEALTH SERVICES OF RHODE ISLAND
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH SERVICES OF RHODE ISLAND
Other - Org Name:PSYCHIATRIC HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:SNR. VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:CFO
Authorized Official - Phone:401-456-3000
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:N. CAMPUS BUSINESS OFFICE, ATTN; R. SOARES
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-456-2525
Mailing Address - Fax:401-456-6742
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3649
Practice Address - Fax:401-752-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI110104100000X, 2084P0800X
RIHOS00110273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No273R00000XHospital UnitsPsychiatric Unit
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISJ09468Medicaid
RI809005170Medicare PIN
RI41S005Medicare Oscar/Certification
RI269006827Medicare PIN